A study of family involvement in case reviews Messages for ......(2012) A Study of Family...

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Child Abuse Prevention, Child Abuse and Neglect

A study of family involvement in case reviews

Messages for policy and practice

Kate Morris University of Nottingham Marian Brandon University of East AngliaPaul Tudor Independent Safeguarding Advisor

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FOREWORDThe death or very serious injury of a child from abuse or neglect calls for careful consideration of the circumstances to ascertain whether lessons can be learnt and changes made that might improve the quality of services in all cases and prevent or reduce the likelihood of such events occurring again.

Beaten and starved, Dennis O’Neil died in January 1945 when the framework of statutory responsibilities and interagency working was weak. The inquiry into the circumstances identified lessons and made recommendations. Over subsequent decades a series of high profile inquiries followed the deaths of individual children and were catalysts for changes in legislation and social policy.

Many other children whose deaths were due to abuse or neglect did not attract the attention of the media, public or government sufficiently for their circumstances to be the subject of any inquiry. It was recognised that if outcomes for vulnerable children were to improve and serious incidents reduced, lessons from these cases should also be learned to improve services.

The strategic interagency child protection committees introduced by government guidance across the countries of the United Kingdom were subsequently required to carry out interagency reviews.

Driven by practice experience and human rights principles it was acknowledged that children and families should be included in processes that impacted on their welfare and circumstances. Guidance issued in relation to case reviews first anticipated and later required that family members should be involved in the review processes. Families and others close to the child are entitled to be helped to understand how the events occurred

and to have confidence those necessary changes will be made. They are more familiar than professionals with the impact of services delivered and might have a significant contribution to make.

The British Association for the Study and Prevention of Child Abuse (BASPCAN) is a multi-professional charitable association with objects that include the protection of children from suffering, or likelihood of suffering or significant harm through education and learning. The membership is drawn from all the countries of the United Kingdom and across all professions concerned with child abuse and neglect. We publish Child Abuse Review, a peer reviewed journal six times a year with an emphasis on practice, organise every three years a National Congress with an international reputation for a high standard of content and convene conferences and other training events. We also fund small pieces of research that are unlikely to attract funding from traditional sources and have a practice emphasis.

The experience of many members of the Association has been that the extent to which family members and others who knew the child well have in practice been involved in the review processes has been inconsistent. Often there has been no or only token involvement. The reasons for involvement have not been understood or reflected in practice. Uncertainty about who, how and when individuals should be involved has undermined the purpose and the intended impact and positive contribution that they might have made.

BASPCAN Trustees considered it important to act on the reports of its members and take steps to understand the extent to which Child Protection Committees and Local Safeguarding Children Boards across the countries that make up the United Kingdom carry out their responsibilities in this area, the actual experience of families, and examples

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Contents Page number

ACKNOWLEDGMENTS 6

EXECUTIVE SUMMARY 7

THE STUDY 13

SETTING THE SCENE 17

NATIONAL AND LOCAL POLICY ANALYSIS 23

PROFESSIONAL REFLECTIONS 29

FAMILY EXPERIENCES 39

RESEARCH SUMMARY AND PRACTICE 53RECOMMENDATIONS

REFERENCES 66

of good practice, in order to identify how arrangements might be improved. Whatever processes are developed for reviewing cases, an emphasis on learning will require the involvement of family members.

BASPCAN therefore decided to commission independent research and was pleased to be able to engage a team with reputations for high academic standards and extensive experience of practice in this area.

Kate Morris is Associate Professor in Social Work at the Faculty of Social Sciences, University of Nottingham. Dr Marian Brandon works at the Centre for Research on the Child and Family, University of East Anglia. Paul Tudor is a social worker with extensive experience as an Independent Overview Report Author.

We are grateful for the energy and enthusiasm that the team have applied in carrying out this research and producing this Report. In particular their work has enabled the voice of family members and that of a range professionals practising in this area to be reflected.

It was important that the research considered the arrangements across the United Kingdom and we thank the large number of professionals who participated in the consultation meetings that were held in all the countries and formed an integral part of this study. Their collective experience and expertise provided a rich source of learning.

We welcomed the assistance, interest and enthusiasm of colleagues in government offices and local authorities, and members of BASPCAN branches for facilitating and encouraging the meetings to take place.

Most importantly we acknowledge and thank the members of the families who shared their experiences and ideas with the research team.

The involvement of family members/significant others should of course include children, the survivors and siblings of children who have died and those that knew them well. However, it has become apparent that children’s involvement in case reviews occurs so infrequently that BASPCAN realised that a separate piece of work concerned with developing child participation is required and will be working with experienced partners on this project.

It is expected that the content and recommendations in this Report will challenge and change individual practice and the management of reviews and make a significant contribution to the development of government policy.

Jonathan PickenHead of Partnership

David SpicerVice Chair of BASPCAN

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ACKNOWLEDGEMENTSThe research team have been well supported throughout this work by BASPCAN, we have appreciated their help in identifying useful networks and individuals, the support they offered for the focus groups and consultation events and their willingness to accommodate the amendments and changes to the work necessary in such an exploratory study.

Particular mention should be made of Jonathan Picken, David Spicer, Catherine Powell and Judy Sanderson.

We have also valued enormously the input from experts within the field – too numerous to name but their willingness to share their knowledge and time was greatly appreciated. Without their involvement this report would not be possible.

A particular mention must be made of the families who participated in this research. They were keen to see changes in the practices and processes for family involvement. Their willingness to share their experiences was essential in making the research and the guidance relevant and useful.

We would like to also acknowledge the assistance of the following groups: the Victoria Climbé Foundation, Advocacy after Fatal Domestic Abuse (AAFDA), Family Rights Group and the Local Safeguarding Boards that facilitated access to families.

It should be noted that the views expressed in this report are those of the authors and not necessarily those of BASPCAN.

EXECUTIVE SUMMARY 1. The Study

The UK policy expectations for family involvement in case reviews have not been matched by allied developments in practice guidance. The study set out to address the following questions:

• What are the current arrangements for participation as set out in local protocols and procedures in England, Northern Ireland, Wales and Scotland? • What are the experiences of families who have participated in reviews and what learning can be drawn from these experiences? • What are the professional experiences of family involvement? • What conclusions can be drawn for guiding effective practice?

The research was reviewed and approved by the University of Nottingham research ethics procedures and careful safeguarding arrangements were adopted. The study consisted of five, interlinked stages:

1. A review of all published guidance across the four UK countries 2. An initial series of expert focus groups that supported the fieldwork design 3. Telephone interviews with policy makers / practitioners with particular expertise 4. Interviews with family members who had participated in case reviews 5. A final series of consultation events across the four countries.

2. Professional Experiences

The purposes of family involvement: four themes emerged

A rights perspective: Professionals argued that for parents and close family members involvement was a rights-based issue. Participants identified an analogy to the development of family participation in Child Protection Conferences, which also addressed issues of rights and responsibilities.

Good practice: a child-centred perspective: Professionals’ responses indicated that family involvement was the closest point when seeking to understand life through the eyes of the child. Report authors talked about specific material that the family might offer that gave the child a real identity, including, for example, photographs of the child. Such material was seen as placing the child in the centre of the process.

A view that the family holds key information which will inform learning and contribute to the change process: Participation triangulates information and minimises assumptions being made based solely on case records or agency reports. Family narratives about services held key information which was unique and the dynamic of the family was also seen as relevant to the learning, providing the authors with an insight into family life and the professional encounters.

When citing this report the full reference is:

Morris, K., Brandon, M. and Tudor, P. (2012) A Study of Family Involvement in Case Reviews: Messages for Policy and Practice BASPCAN

ISBN - 13 978 085358 287 8

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An altruistic and cathartic element: Whilst professionals recognised that this was not an overt or explicit purpose of family participation, the review could help families cope with their feelings and the aftermath. However, there was a clear understanding that the review could not be a process of therapy or support for the family.

Who should be involved?

In almost all responses an inclusionary approach to eligibility was adopted, but there was a note of caution in not spreading the net too wide and ensuring that the primary purpose was kept in mind. The analysis indicated that there were three caveats to be taken into account when exploring who should participate:

• A duty of care in the context of, for instance, vulnerability and mental health issues • Clarity and sensitivity about antagonistic internal family relationships • Very careful consideration was needed when involving children.

A further, fourth caveat emerged from the consultation events. Review authors were being limited, in some areas, in terms of the number of family members they could interview or seek to involve because of funding restrictions. Hindrances and barriers to family participation

Four common themes emerged when exploring potential barriers to involvement:

• Practitioners and their agencies could be over-protective of their own reputation and credibility when managing the process of participation • Boards and Review Panels could be fearful of the responsibility of the raw emotions generated; and could also be anxious that the process would generate harm and turbulence • Some families and significant others refused to participate based on their previous negative experiences of professionals• Very often a rationale for the decision to not offer opportunities for family participation is concurrent legal proceedings. In general our evidence indicated that seeing family members pre-trial was possible; it was a matter of timing and negotiation with CPS/Police/lawyers.

Publication of the full Overview Report

This was a topic that generated strong views and feelings and there was a consensus of opinion that family information needed some moderation if publication was likely, in order to protect surviving family members. For some professionals, when redaction was taken to an extreme in order to protect the family, the risk was of the report becoming a meaningless document which defeated the objective. There was also a danger that the process resulted in partial reports and fuller accounts being shared informally. A theme emerged of approaches that sought to question when and why publication would be useful and that a sense that change could be achieved without publication.

3. Family Experiences

The Initial Stages of the Review Process: The services and practices that were delivered immediately after the critical incident that necessitated the review were uniformly experienced by families as confusing and difficult to comprehend. The families were aware of underlying professional anxieties about risk to reputational credibility and professional identity, and some family members understood this anxiety to be detrimental to the practitioners’ ability to respond appropriately to the families’ experiences and needs. What was experienced as poor, chaotic practice at this time often mirrored for families preceding experiences of professional interventions. Skilled practice was required and when encountered was particularly appreciated. For families the quality of practice immediately after the events that led to the review was connected to the quality of any preceding services / practices. It was instrumental in determining their approach to participation in subsequent processes and interventions, and their expectations and aspirations for the review.

The Drivers for Participation: Family reasons for participating in the review varied, and as a result their experiences of the review differed. For all the families the role of the review in promoting and supporting change to prevent further trauma and loss for other families was a key impetus for participation – whatever the circumstances leading to the death or injury of the child. Family narratives suggested that the drivers for their participation included:

• To know more about the lived experiences of the child• To understand better the critical incident(s) and the responses pre and post events • Giving voice to the child and to the family (including issues of justice) • Resolution and repair• Changing and influencing processes and practices.

The Process of Participation: In drawing together family experiences, the analysis suggested a number of themes arising from the process of participation in a review:

• A confusion about the relationship between different procedures and the remit of each process• A tension between process adherence when set against the responsivity needed to address family trauma and loss• The process by which the ‘rules of engagement’ and the focus of involvement (who/how) are decided, and the family role in this activity • The need for practice that engaged with the emotion of the situation and family experiences• Taking care and careful practice, including how family information was used and how accuracy was ensured.

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The Impact of the Review: The impact of the review was linked to arrangements for understanding any sustained, long term change. Whilst the experiences were diverse, thematically the experiences that influenced the impact of the review on families can be summarised as:

• the extent to which families had witnessed change and their perceptions of the impact of the outcomes of the review on their lives and the lives of other children• family understandings about how their contributions would be used and represented in the outputs (including the effects of publication and publicity) • the extent to which careful relationships with professionals engaged in the review were built and sustained • the access granted to final reports, set against the concerns about disclosure and identification • the reality of dealing with trauma and loss when professional procedures (including the review) had drawn to an end.

The Skills and Practices Required: Drawing together the family narratives, the skills and practices that were valued and facilitated participation included:

• Robust, well developed interpersonal skills, including rapport building and careful sustained communication• Careful mapping of the family and their relevance to the review • Skilled use of interpreters and translators to ensure full participation • Practices that demonstrated care and recognised the realities of families’ lives• Access to the learning and the proposed plans for change beyond the executive summary.

4. Practice Recommendations

Whilst the research project was able to include young people and professionals who had experience of child participation in reviews, the extent of child involvement in practice was impossible to gauge and it was therefore difficult to arrive at any firm conclusions. Consequently, this set of recommendations focuses on adult involvement and further work is needed to a) understand the purpose and extent of child participation in existing practice and b) the shape and nature of best practice in children and young people’s participation in case reviews.

Principles for Policy

The findings from this study suggest that family involvement has the potential to make an important contribution to the learning from reviews of the most serious cases of child death or serious injury arising from abuse or neglect. This study of family involvement suggests that guiding principles rather than prescriptive practice is well suited to the policies and practices of family participation. The evidence indicates that the principles grounded in clarity, transparency, negotiation and inclusivity can usefully inform family involvement.

The Purpose of Participation

The research revealed a range of reasons for family involvement in case reviews. But it also revealed that agencies rarely make clear why they seek family involvement in the review processes. The various terms adopted to describe participation (‘engagement’, ‘involvement’, ‘consultation’) suggested clarity is needed. In order for families to become involved in a manner that avoids further harm, and for professionals to be clear about their involvement, there is considerable value in local protocols being transparent about the reasons for seeking family involvement.

Who should participate?

A useful and appropriate framework for inclusion is “families and significant others” and the criterion should be any one who was important to that particular family system, the key individuals in the life of the child and their family. Decisions about which family members and significant others should be included must be made on a case by case basis (based on assessment of feasibility and vulnerability). Good practice (in terms of supporting maximum learning) would seem to be an open inclusion criteria without any pre determined exclusions.

How, Where and When?

The research indicates that the type and nature of family participation hinges on the scoping stage of the review. Whilst the specific details of the terms of reference for each review are developed case by case, general guidance for setting the terms of reference should include opportunities for the family to contribute to this early stage, and for the nature and type of their participation to be mapped out very early on in the review process. The study suggests four phases in engagement with the family and significant others:

Phase One: initial contact and mapping of the review (purpose, remit, and relationship to other processes), identification of any specific support needs of family including use of interpreters and advocates.

Phase Two: negotiation (where possible) of Terms of Reference, agree type and process of involvement, mapping of family members to be involved, facilitation of family preparation including setting out how family information will be used.

Phase Three: substantive gathering of information, including family descriptions of experiences, agreement about ongoing contact and feedback arrangements.

Phase Four: feedback, fulfilling commitments concerned with reporting actions and change, family evaluation of process.

5. Family Guide

We conclude by offering a brief information sheet for family members (at the end of the full report). Family members participating in this research had the opportunity to read and review this guide.

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1. INTRODUCTION1.2 The Study

The research was commissioned by BASPCAN, in response to suggestions made by the research team. The ongoing policy expectations for family involvement have not been matched by allied developments in practice guidance, and the research team were aware of uneven developments across the UK in local approaches. The study was commissioned to draw out learning for policy and practice, reflecting a desire that unhelpful or harmful practices and policies might then be avoided. Specifically the study set out to address the following questions:

• What are the current arrangements for participation as set out in local protocols and procedures in England, Northern Ireland, Wales and Scotland? • What are the experiences of families who have participated in reviews and what learning can be drawn from these experiences?• What are the professional experiences of family involvement?• What conclusions can be drawn for guiding effective practice?

1.3 Methodology

Searches of the literature suggested that no other comparable UK studies have been developed. This, coupled with the emotive and difficult subject matter meant that an exploratory study that allowed the research design to be responsive to the emerging findings was necessary. The primary intended outcome of the project was to support learning and practice in family involvement and this focus on learning shaped the design of the research and the analysis of the data. The study consisted of five, interlinked stages:

1. A review of all published guidance developed by local safeguarding agencies / boards across the four UK countries. The desk research reviewed the material available via the websites of the local safeguarding organisations, and where appropriate followed up the initial search with further explorations if specific guidance was mentioned. This documentary review allowed the research team to understand the policy and guidance contexts when subsequently examining practice.

2. An initial series of expert focus groups that supported the research team in developing the fieldwork design and reflected upon initial findings from the documentary review. These focus groups were also able to consider the data from the early pilot interviews with professionals and families.

3. Semi structured telephone interviews with independent report authors, board managers and individual policy makers / practitioners with particular expertise in family involvement to elicit information about current practices, challenges and localised developments.

4. Unstructured interviews with family members who had participated in case reviews to capture their experiences and reflections, using previously agreed prompts where appropriate.

5. A final series of consultation events across the four countries to consider the early analysis of the data and to test out the practice recommendations.

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The exploratory nature of the study meant that each stage / strand was informed by the learning from the other strands. Symmetry across the project was achieved by ensuring the professionals and the families were interviewed using common schedules / prompts, and each set of the focus groups used the same frameworks and questions. The process of ‘snowball sampling’ adopted with the professionals meant the research team were able to hear from those with specific and directly relevant expertise, although the limits to this approach are acknowledged (Browne 2005).

The early focus groups of experts assisted in this sampling process – the participants were able to identify through their networks those professionals who had substantial experience of family participation. These professionals were asked to participate in individual telephone interviews and as before, they then also identified professionals with relevant expertise. The interviewing continued until it became evident responses were becoming repetitive and common data was being generated.

Participants were drawn from all four UK countries and reflected a mix of urban and rural locations, all held substantial relevant experience in policies and practices for family involvement. A call for contributions by BASPCAN also generated professional responses, further extending the sample size. In total 139 professionals were interviewed or provided written responses. The professionals who contributed included report authors, board managers and chairs, policy makers, service managers and designated policy leads.

An initial analysis of the professional responses was tested out with a further expert focus group to ensure the analysis was the subject of some internal verification and examination. Finally, the combined learning emerging from all the strands of the project was discussed in a series of consultation events across the four countries, allowing the practice recommendations to be reviewed and amended / extended.

The family interviews were undertaken throughout the life of the project concluding only when the final stages of the analysis were underway. The research presented ethical and safeguarding concerns and families were informed of the responsibilities of the researcher to alert the referring agency (where applicable) to any safeguarding issues that might arise.

Family interviews were taped and transcribed and all the families were offered the opportunity to review and discuss the findings of the study during the draft stages. The research was reviewed and approved by the University of Nottingham research ethics procedures and appropriate safeguarding arrangements were adopted.

Accessing families proved to be the most demanding aspect of the fieldwork. The research team followed up numerous initial positive contacts from professionals who felt the Boards / agencies they had links with would be willing to alert families to the research. The Boards and professionals who had formal engagement with the families were then approached to ask if they would facilitate contact with the family. While some families were contacted, in other cases multiple reasons were given for the reluctance of the Boards to approach families:

• Concerns about disruption of current work with the family • Concerns about ownership of the data from families (particularly if of a sensitive and critical nature) • Concerns about current events in the family’s life preventing participation • Concerns that families would not want to participate • A view that the past difficulties in working with the family / failure by the family to co-operate curtailed the rights of the family to engage with a research project. These responses should be understood in the broader context of approaches to family involvement in reviews. The responses to the research project indicated that there are ethical and practice restrictions to participation, and implicit professional assessments of families needs and rights in relation to participation. Through the assistance of safeguarding professionals, family advocates, self help groups and open calls for family contributors representatives from seven families were interviewed, and two advocates for families whose children were the subject of case reviews. To avoid any possible identification of the families, no descriptive information is provided, however all those participating had experienced significant loss and trauma and had a diverse range of past and current welfare services intervening in their lives.

The use of unstructured interviews allowed family narratives to reveal anticipated and unanticipated themes. The data gathered from families was analysed with a focus on eliciting learning for policy and practice. Through a process of coding and categorisation the initial analysis sought to identify common themes across the data, with this initial analysis being refined through the reflections and suggestions of the focus groups and the consultation events. Families also provided an internal reviewing process, reading and commenting upon early drafts of the report. This approach allowed the learning for practice and policy to be explored and its relevance tested, it also allowed questions for future research to be identified.

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1.4 The report

The report has five sections. The first considers the current framework for family involvement including regional and national policies. It also considers new, emerging models of case review and their implications for family involvement. The second and third sections draw on the learning from national reviews of local case reviews and the documentary analysis of local policies and procedures completed in the early stages of the research. The fourth section presents an analysis of the professional responses and the common themes that emerged when examining existing policy and practices. The fifth section draws together the family experiences of participation. The final section can be read as a ‘stand alone’ guide for developing policy and practice; it does however draw carefully on the preceding sections.

This final section includes recommendations for policy, for practice and guidance for families.

The report uses a series of terms which require clarification. We adopted a broad understanding of ‘family’ and thus the term is used loosely to include all those in the child’s network – recognising that this would be unique to each child and would include relatives and significant others. This draws on empirical evidence from family minded practices elsewhere (Morris et al 2009) and provided an appropriate framework for the analysis. The terms engagement, participation and involvement are, to some extent used interchangeably, this reflected their use in the policies and practices we examined. However, in the concluding section we make suggestions about the principles of family involvement that might help clarify the use of these terms.

The analysis indicated that ‘engagement’, ‘participation’ and ‘involvement’ covered a diverse set of practices including notification, consultation, information sharing, direct influence on the professional processes and foci and active roles in monitoring and reviewing outputs.

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2. SETTING THE SCENE

2.1 Background

Serious case reviews (England and Wales), case management reviews (Northern Ireland) and significant case reviews (Scotland) are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected. Case review processes differ throughout the UK but all are carried out so that lessons can be learnt locally to improve interagency working and the protection of children.

These reviews have been an important source of learning for many decades. The first national requirement to hold local reviews in these circumstances in the UK was the England and Wales guidance Working Together in 1988 (Department of Health, Department of Health and Social Security and Welsh Office, 1988). Although influential individual Inquiries had been held before, 1988 was the first time that there had been any national guidance about multi-agency working in child protection, and the first time there was any expectation of local reviews of the most serious child abuse cases. Prior to this, local areas around the United Kingdom devised their own approaches and policies for child protection.

The 1991 edition of Working Together added some more detail to the brief guidance about ‘Part 8 Reviews’ (as they were then known) and offered general principles for carrying out a review, leaving the detail to be determined locally by Area Child Protection Committees (ACPCs) (Home Office, Department of Health, Department of Education and Science and Welsh Office, 1991). These six principles were: Urgency, Impartiality, Thoroughness, Openness, Confidentiality, Co-operation and Resolution (Home Office et al 1991:57-58). Although family involvement was not specifically mentioned or required at this stage, the principles of partnership with families supported by legislation in all four nations of the UK (for example the England and Wales Children Act 1989, the Children (Northern Ireland) Order 1995 and the Children (Scotland) Act 1995) made engaging with families in the review process possible and even likely. Further, a number of previous high profile Inquiries had interviewed and involved families, thereby creating some precedent for family engagement in the review process.

During the 1990s it gradually became more commonplace to include adult family members, and sometimes children, in child protection conferences. The learning from research and from the positive outcomes stemming from these changes resulted in the general acceptance of family involvement in multi-agency child protection as good practice in all the four nations (DH 2001). By 1999, Working Together in England (Department of Health et al, 1999) and a different version in 2000 for Wales (National Assembly for Wales, 2000), had moved from a statement of general principles in multi-agency child protection practice, to greater levels of prescription including in the handling of the review. This, like the Co-operating to Safeguard Children guidance in Northern Ireland (Department of Health, Social Services and Public Safety, 2003), included the requirement to consider whether family members should contribute to the review process and the need to give feedback from the review to family members. Similar potential inclusion of family members in the review existed in Scotland’s 2007 Interim Guidance for Child Protection Committees. By 2006 the publication of a further revised Working Together (HM Government, 2006) in England and of Safeguarding Children: Working Together under the Children Act 2004 (Welsh Assembly Government, 2006) had taken family participation in the newly termed ‘serious case review’ a step further presuming their involvement and asking:

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‘How should family members contribute to the review, and who should be responsible for facilitating their involvement” and ‘How should any public, family and media interest be managed before, during and after the review?’(HM Government 2006:8.11).

Further details about the latest England guidance (HM Government 2010) is considered in the next section on current policy guidance in the four nations. The context, and to some extent the purpose of family involvement in reviews are also explained by Human Rights Acts.

2.2 Human Rights and Reviews

Human rights legislation frames child protection policy and practice, and acts as a further driver for family involvement in reviews. Three articles in the Human Rights Act 1998 are particularly influential. These are Article 2 (right to life), Article 3 (rights to protection which include abuse and neglect) and Article 8 (right to respect for private and family life). Article 2 states that ‘Everyone’s right to life shall be protected by law’ and places an obligation on the state to investigate where public authorities might have contributed to the death, either by omission or commission (Rose and Barnes 2008:28). Rose and Barnes were among the first authors to point out that the state’s obligations to carry out a serious case review related to Human Rights legislation.

Together, all these articles encompass a responsibility to carry out sufficient inquiry which must include accessing material and considering contributions from those who are aware of material that is relevant. This acts as a significant prompt for involvement of the family including the child and others close to the family. Citizens have an interest in knowing how the state has acted in carrying out the enquiries and what has been done in response so that they can form a judgement about whether the state and its agents are properly carrying out these responsibilities. This is also where the obligation to publish the Executive Summary of overview reports originates. Those citizens who may have a particular interest and right to know include family members and others with a specific interest.

Article 8 concerns the right to respect for private and family life, including personal relationships. The courts have interpreted this as encompassing an obligation by the state to include the rights of those who are engaged in processes that impact on family and private life and to take account of what they have to say. This is an additional driver for both the inclusion of family members and others in the review process and to ensure they are properly informed about the outcome – in other words to show appropriate respect for their family and private life. It also has an impact on the arrangements for publication since appropriate respect should be shown for the impact on private and family life of individuals.

The United Nations Convention on the Rights of the Child, also underlines the state’s responsibility to ensure to the maximum extent possible the survival and development of the child. Article 12 reinforces the need for children’s views to be given due weight in accordance with the age and maturity of the child. This is widely interpreted as requiring the participation of the child in processes and procedures and decision-making that affects the child. For surviving children and siblings this drives participation of children in the review process.

2.3 Messages about Family Involvement from Research and Biennial Analyses of Reviews

Published research about reviews and the review process provides a base line for what is already known about family participation. A study undertaken by Sidebotham and colleagues (2010) found that almost three quarters of those questioned about serious case reviews in England, agreed that family involvement enhances learning. Respondents commented, however, that the method and purpose of engagement were not straight forward and there was no clear view about whether families can and should be holding agencies to account as part of this engagement.

A similar study in Northern Ireland (using the same ‘Delphi’ method) also found mostly positive responses but also mixed views about family involvement (Devaney et al 2011). Positive aspects of involvement were that it created transparency for families and allowed them to share perspectives with the review panel, thereby creating a more holistic overview of the situation. However, it was felt that it could also provoke stress in agencies and in Area Child Protection Committees; not least the anxiety that it might prompt the family to seek someone to blame and that it could discourage professionals from engaging with the review. An analysis of 24 case management reviews completed in Northern Ireland 2003-2008 found that family members and significant others were involved in 17 of the cases (Devaney et al., in press) although the scale and nature of this involvement is largely unknown.

Rose’s 2009 report for the Care and Social Services Inspectorate in Wales also underlined the considerable tension surrounding the expectation of family involvement in reviews and the confusion about how to facilitate and carry this out across Local Safeguarding Children Boards (LSCBs). It also highlighted the uncertainty about families’ legal rights to access single agency and overview reports which potentially become public (CSSIW 2009:12). The, as yet unpublished, study of recent serious case reviews in Wales, found a somewhat less ‘problematised’ situation with some positive examples of family contributions and evidence that families had been involved in seven of the eighteen case reviews examined (Brandon et al/WAG unpublished). One review from this study stated that family can give a clear sense of the child as a person. ‘The help of x and x’s family has been invaluable; many important points would not have emerged without their assistance.’ Although family contribution is an expectation in national level guidance in Wales, some families from this study were not given the opportunity to participate which confirms the tensions and the variable practice mentioned by Rose (CSSIW 2009).

The Government in England has commissioned and published five consecutive two yearly analyses of serious case reviews that have taken place since 1999. Sinclair and Bullock’s study made the criticism that in spite of the requirement in Working Together 1999 to consider the involvement of family members, families were, on the whole, excluded from the review process, and this limited any learning (Sinclair and Bullock 2002). Rose and Barnes found evidence of family involvement in one in five of the 40 reviews they examined from 2001-2003 and noted the added complexity that this brought to the review process (Rose and Barnes 2008:35). They identified the difficult balance to be struck between individual rights (to be heard and to privacy) and the public interest - which remains a contemporary challenge particularly in the light of the move to publication of the review. They also noted a potential tension between family members’ influence in the review and the need to hold a dispassionate inquiry into events. In one case where family

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members were involved, Rose and Barnes warned that this unhelpfully shifted the focus of the review away from the child who died to the needs of the adults who had killed the child. In spite of these difficulties and tensions many respondents in the Rose and Barnes study were positive about the important contribution that family members could make to the learning from a review. For the experience to also be positive for families it was important for any contacts to be sensitively handled and for them to be well supported and kept informed throughout the process through something akin to a police family liaison role (Rose and Barnes 2008:36).

Families contributed to nine out of forty seven English serious case reviews studied in depth from the period 2003-05 (Brandon et al 2008). By 2005-7 family contribution to the review was still perceived to be complex and difficult but was becoming much more commonplace (Brandon et al 2009). Those LSCBs with positive experiences of facilitating family involvement tended to be more confident and more likely to repeat the experience. The three persistent barriers found to prevent families from even being invited to participate by LSCBs, were on-going court proceedings, difficulties posed by the tight timescale of the review and perceived family sensitivities. The study recommended that positive practice and experiences of LSCBs needed to be communicated more widely through training and website links (Brandon et al 2009).

Ofsted’s reports of English SCRs have questioned the amount of effort invested by LSCBs in securing family participation and noted that there is considerable variability in this respect across the country (Ofsted 2008, 2010). Their 2010 report notes progress however, with family participation becoming much more the norm. Although some family members still did not respond to or declined invitations to participate, in 32 of the 63 cases studied, there were positive responses from a wide range of family members, which included participation from nine young people (Ofsted 2010:36). Ofsted found that early involvement was helpful and could shape the questions to be considered at the outset of the review:

‘In the best examples, there was far more than a tokenistic response to the requirements of ‘Working Together’: the views of the family were woven into the final report and had an influence on its findings. It was not sufficient, as happened in one serious case review, to add parental views as an appendix without referring to these views in the body of the report. By contrast, in a case where the overview report was judged to be outstanding, there was an excellent account of the parents’ contributions, including the mother’s retrospective views about being allowed to care for her baby. Information from a meeting with the father provided an account of his background. This filled in many of the gaps that the individual management reports had been unable to address. The overview report was able to reflect on the comments made by the father about the involvement of services’ (Ofsted 2010:37).

2.4 Alternative approaches to reviews

There are a number of different approaches to carrying out reviews which have implications for family involvement. In some circumstances where a child has been injured there may be an element of discretion about whether to hold a full case review and an alternative review process may be held when it is considered to be a better way of learning lessons (Brandon et al 2010). These are sometimes called ‘Lessons Learned Reviews’ or reviews following ‘Near Miss Procedures’. Others use an Appreciative Inquiry model (Cooperider and Whitney 1999) or a workshop oriented rather than solely paper-based approach as in the Significant Incident Learning Process (SILP). Many alternative models of review, like the SILP, are planned to be less time consuming and to get the messages for learning out more speedily and efficiently. This is also intended in the draft revised Welsh process for Multi-Agency Child Practice Reviews (currently out for consultation), which provides for either a ‘concise review’ or an ‘extended review’ (WG 2011). An important part of both the concise review and the extended review is a learning event. Family members are expected to contribute to the learning event and to the review processes as a whole.

The Munro Review (2011) recommends that in England a systems approach be used to carry out reviews where a child has died or been seriously harmed as a result of abuse or neglect. This model has some similarities with ‘Root Cause Analysis’ which is commonly used in the health sector and moves away from a prescriptive approach to ‘explicitly focus on a deeper understanding of why professionals have acted in the way that they have, so that any resulting changes are grounded in practice realities’ (Munro 2011:61). The emphasis is on professional learning rather than the family’s story and on increasing professional capacity and expertise. These proposals build on the Social Care Institute for Excellence (SCIE) model of systemic review ‘Learning Together’ (Fish et al 2008) which was developed to learn lessons from complex cases. The approach is currently being trialled as a way of carrying out a serious case review.

There are two key issues stemming from this particular systemic approach to carrying out the review in relation to family involvement. The first is that since the emphasis moves away from the family story, the child as a person in their own right may not be at the centre of the review, (although the family’s understanding of events can potentially be included). The second is that the report, when published, will not put any information about the family in the public domain. The issue of publication of the report is discussed later.

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2.5 SummaryReviews provide an important source of learning and throughout the history of reviews into these most serious cases of child abuse, family members have had an important contribution to make to this learning. ‘Taking the family with you’ in the process is underlined by Human Rights legislation which also highlights a tension between public interest and accountability and the family’s right to respect for family life and privacy. These and other tensions are also reflected in the research and literature base about family involvement in reviews. Most are agreed that family participation enhances learning and creates more transparency for families but it also provokes stress among agencies. While in some nations it appears that family involvement is on the increase, there are still widespread barriers to engaging families particularly on going court proceedings, the tight timescale for the review and perceived family sensitivities.

3. NATIONAL AND LOCAL POLICY ANALYSIS

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3. NATIONAL AND LOCAL POLICY ANALYSIS3.1 National Policy

In line with the partnership principles of the legislation guiding work with children and families in all four nations, current policies for the review process require (at least) that consideration be given to involving families. In Northern Ireland and Scotland discretion rests with the Safeguarding Boards/ Child Protection Committees about whether, and how to involve families. In England and Wales there is a stronger, national level requirement that Local Safeguarding Children Boards (LSCBs) consider how to involve families and who will be responsible for this. All four nations are in the midst of revising their guidance about this review process which makes our study timely. The current guidance about family involvement (at the time of writing) in Serious Case Reviews in England and Wales, Significant Case Reviews in Scotland and Case Management Reviews in Northern Ireland is, however, summarised here.

Northern Ireland

In Northern Ireland, current national guidance for involving families in the Case Management Review comes from Chapter 10 of Co-operating to Safeguard Children (DHSSPS, 2003). Consideration about whether or not to engage with family members occurs at the point of determining the scope of the review (10.16) and when the report has been completed (10.32):

• should family members or concerned individuals, who may have referred the case to social services, be invited to contribute to the review? (para 10.16)

• how should any public, family and media interest be handled, before, during and after the review? (para 10.16)

• make arrangements to provide feedback and de-briefing to staff, family members of the child whose case has been reviewed and the media as appropriate (para 10.32).

Scotland

Interim guidance for carrying out significant case reviews was issued in 2007. The document Protecting Children and Young People: Interim Guidance for Child Protection Committees for Conducting a Significant Case Review (Chapter 6), amended in 2010 (Multi Agency Resource Service [MARS] 2010), acts as current policy in Scotland. As in Northern Ireland, discretion rests with the Child Protection Committee about whether to involve families. However this guidance offers more detail about how to manage the involvement and support of families than any of the other three nations’ current national guidance (Vincent 2009), The guidance is summarised here:

• Whether family members are to be invited to contribute to the review …• Who the liaison point for the child (if alive) will be, and/or for their family/carers• Where interviews with contributors will take place; • What briefing will be provided for contributors, and by whom (para 72).• The family/carers of the child involved should be kept informed of the various stages of the review and the outcomes of these where this is appropriate. (para 78)

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• There may also be cases where families are looking to take legal action against an agency or agencies that are the subject of the SCR. Individual agencies’ complaints procedures should be made available to the family (para 79).• Care should be taken about where and when a child or their family/carers are interviewed. Reviewers should be experienced in communicating with children. It may also be useful to assign a member of staff to be a liaison point throughout the review. The person carrying out this liaison role should be fully aware fully of the sensitivities and background of the case. This person’s role could include advising the family of the intention to carry out an SCR and making arrangements to interview the child, family/carers or significant adults involved (para 80).• …the expectation is that the full report will normally be published and that the Executive Summary and Recommendations will always be published. Family/ carers and/or other significant adults in the child’s life should receive a copy of any report in advance of publication (para 81).

The MARS report (2010) found that family involvement was not dealt with in a consistent way across Scotland and can be a cause for anxiety. It also highlighted the benefits of ‘involving and taking the family with you’ (MARS 2010:21).

Wales

The expectation of the involvement of family members in serious case reviews has been evident in Wales since the 2006 publication of Working Together 2004 (in Chapter 10). As in the other nations, engagement with families is first considered and planned at the scoping stage.

• How should family members contribute to the review and who should be responsible for facilitating their involvement? (p252). • How should any public, family and media interest be handled before, during and after the review (p253).

Draft guidance, issued by the Welsh Government for consultation in December 2011, provides more detail about family involvement and how it might be managed. The new arrangements have a wide interpretation of significant family members and include contacting family members to ask about the messages or questions they would want to contribute to the review’s learning event. The guidance also emphasises the quality, skills, knowledge and experience of the reviewer in facilitating the involvement of family members throughout the review. Family involvement is one of the principles of the new proposed framework:

‘It involves agencies, staff and families in a collective endeavour to reflect and learn from what has happened in order to improve practice in the future, with a focus on accountability and not on culpability’ (Welsh Government 2011:1)

England

England’s current serious case review guidance comes from Chapter 8 of Working Together 2010, (HM Government 2010). As in the other nations, family involvement is first considered when determining the scope of the review. The 2010 guidance offers a wider interpretation of family than previous documentation in Working Together 2006 (HM Government 2006). Like the 2006 guidance, Working Together 2010 presumes that family members will be involved throughout the review process:

• How should the child (where the review does not include a death) surviving siblings, parents or other family members contribute to the SCR, and who should be responsible for facilitating their involvement? How will they be involved and contribute throughout the overall process? • How should any family, public and media interest be managed before, during and after the SCR? In particular, how should surviving children (where appropriate given their age and understanding) and family members be informed of the findings of the SCR? (para:8.20).

Interestingly, there is no clear statement about the purpose of family involvement in any of the national guidance. Perhaps the nearest to this is contained in the wording about the purpose of a serious case review in Working Together 2010 which asserts the need for learning about the child to be at the centre of the review:

‘It is essential, to maximise the quality of learning, that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the SCR, irrespective of whether the child died or was seriously harmed. This perspective should inform the scope and TOR of the SCR as well as the ways in which information is presented and addressed at all stages of the process…’ (HM Government 2010:233)

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Family members are often the only people who can offer this knowledge about the child so their involvement is potentially crucial to the learning. In a few isolated instances, local policy documents are in some ways clearer about the purposes of family involvement.

3.2 Local Policy Analysis

We searched for additional local policy and guidance about family involvement in the review process in each of the four nations. For England we searched the websites of 150 Local Safeguarding Children Boards (LSCBs) at an early stage in the study in the autumn of 2009 (before the introduction of Working Together 2010 when they were using the 2006 guidance). The same activity took place for the 22 LSCBs in Wales early in 2010. When similar searches were carried out for Northern Ireland and Scotland, we found no additional local policy documentation to add to the national guidance.

In the searches from England and Wales where we were able to track policy documents, we identified four mutually exclusive categories into which we could group the policies. These are:

• Unavailable / inaccessible (where websites are down, or non existent, or policies are not available)• Basic / minimal (family participation mentioned with stock phrases in the scoping sections and the dissemination sections of the LSCB guidance)• Basic / Enhanced (family participation is mentioned in the guidance and other sections enhance the basic requirements) • Specific developments (LSCBs that have extended guidance, information leaflets for parents, detailed practice arrangements).

Findings from the searches of LSCB websites in England

Most of the 150 LSCBs used basic guidance from Working Together in their protocols although one in five Boards had some limited supplementary policy beyond this. A similar proportion of LSCBs (one in six) provided more elaboration about how involvement would happen and how families would be supported at each stage of the process, including seeking necessary consent and cooperation. They also offered additional local suggestions about practice and policy, for example:

• specifying that families could be provided with the opportunity to contribute written or verbal views • indicating to families what they would be asked • advising panel members to consider how to handle any meeting with sensitivity including the possibility of making a visit to the family’s home.

Some examples of the detail of this type of local guidance are given in the following two extracts one which gives an explanation of one of the purposes of involving families:

‘The involvement of children and family members is a crucial but often neglected area for serious case reviews. The first SCR panel meeting should identify which family members should be involved. This decision should be made without reference to culpability, guilt or the emotive feelings that such cases engender. The person who actually killed or injured the child may have very useful information that can be made available to the panel. The

definition of family should also include grandparents, extended family members and friends of the family. In the case of a young person consideration should also be given to asking their friends to be involved. The purpose of involving family members and friends is that they offer lines of inquiry which will not be present in case records’ (LSCB, England).

‘…There is an expectation that the family (or an appropriate person) would be made aware of the review and asked to make any comments about what has happened and what would have helped them. However, care should be taken in approaching family members directly where there are pending prosecution and/or care proceedings in which an adult and/or children are involved. Exceptionally, where decisions are made not to involve the family, arrangements should be made to feedback the key findings and contents of the executive summary as soon as possible and prior to publication’ (LSCB, England).

One in ten LSCBs in England provided even more detailed, specific, and in some cases very lengthy information about involving families. A few created information leaflets for parents and families and posted these on their websites. The leaflets all described the process, the reasons and purposes for family involvement and how the family would/could be involved and supported, including how to liaise with the serious case review officers.

Findings from the searches of LSCB websites in Wales

In addition to the 22 Local Safeguarding Children Boards across Wales, there are four regional Child Protection Forums and an All Wales Child Protection Procedures Review group. Most of the 22 LSCBs used basic guidance from Working Together (2004). Three Boards from a single Child Protection Forum shared additional local policy and guidance. As in England this offered suggestions about managing the process and supporting the family. These three Boards also posted on the website an example of a letter to send to families and a leaflet for families.

The letter offers condolences on the death or serious harm of the child and notifies the family that a serious case review is taking place, referring them to Chapter 10 of Working Together and the leaflet for more information and giving them a named person as the point of contact for the family. The leaflet for families is written using the following headings:

• What is a Serious Case Review?• What Will I Have To Do? • Why Are You Carrying Out a Serious Case Review?• Who Will Carry Out the Review?• Who Will See the Report?• How Long Will the Review Take?

3.3 Summary

This section has outlined the current policy and guidance about family involvement in reviews in all four nations of the United Kingdom. For England and Wales there is a presumption that family members will contribute to the review. In Scotland and Northern Ireland, Child Protection Committees and Safeguarding Boards respectively, consider on a case by case basis whether family members should be invited to contribute to the review. Interestingly, there is no clear statement in any of the national guidance about the purpose of family involvement.

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All four nations are currently revising their national policies so the detail of how reviews are to be conducted and how this will affect family involvement is in some flux.

Our website search of local policy documents about family involvement revealed that Scotland and Northern Ireland have no local policy to supplement national guidance. In England and Wales most LSCBs relied on stock phrases from the national guidance in the two nations’ separate editions of Working Together. However, a minority of Boards had developed their own detailed procedures, including on some occasions special leaflets for families helping them to understand what to expect from the review.

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4. PROFESSIONAL REFLECTIONS4.1 Introduction

This section focuses upon the content analysis of data from telephone interviews and written responses from nineteen professionals with specific expertise:

• Managers of Local Safeguarding Children Boards, and Child Protection Committees • Overview Report Authors• Lead Reviewers trained in using the SCIE approach• Chairs of Boards• Review Panel members.

As discussed earlier, the referral approach to sampling ensured we were able to trace expertise and arrive at a comprehensive understanding (we ceased sampling once common ground was being covered). We also hosted three focus groups alongside the fieldwork to test out emerging messages, and five consultation meetings across the four countries. These group events brought together 120 colleagues from a range of disciplines and agencies. The scope of this activity has allowed the research team access to a broad range of views and experiences and we are greatly indebted to all those who contributed.

The analysis used the key research questions and the practical steps identified by contributors to secure participation. Interviews were either recorded and transcribed or extensive notes taken (and then checked with the participants). The analysis combined the material to arrive at common themes and reflections upon existing practices.

4.2 Why should families be involved?

Prior to describing and discussing practice, professionals were asked to explore why families might have a role within the review process. The content analysis suggested four common themes when addressing this question:

A rights perspective:

Professionals argued that for parents and close family members involvement was a rights-based issue:

‘The fundamental rights of citizenship, values and ethics.’

Participants identified an analogy to the development of family participation in Child Protection Conferences, which also addressed issues of rights and responsibilities. Reference to the European Convention on Human Rights has already been raised earlier in this report; notably Article 2 “Right to Life” and Article 3 Rights to Protection. Beyond these formal legal frameworks there was also a suggestion that involvement had a role in accountability:

‘It is the best way of holding agencies to account.’

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In other words, participation triangulates information and minimises assumptions being made based solely on case records or agency reports. However, family rights to not participate were also seen as requiring equal respect; parents and other family members could not be forced or beholden to become involved, or indeed pressurised to participate in any way.

Good practice: a child-centred perspective

Professionals’ responses indicated that family involvement was the closest point when seeking to understand life through the eyes of the child. An author described how their report would always have a section entitled “A day in the life of . . .”. By seeking to hear about and represent the child in this way, the child and family were visible and avoided the status of a case number. For authors, the family participation gave the victim (and their siblings where relevant) a voice and was a mark of respect:

‘It humanises the process.’

‘It brings the child much closer.’

‘It makes the child and family real, rather than a paper-exercise.’

‘It brings the child to the centre.’

Report authors talked about specific material that the family might offer that gave the child a real identity, including, for example, photographs of the child. Such material was seen as placing the child in the centre of the process.

A view that the family holds key information which will inform learning and contribute to the change process

Professionals described how family participation brought a unique insight into the delivery of services and of any shortcomings. These, it was argued, can only be identified by the family members. Family narratives about services hold key information which was unique and not shared by other non family members. The dynamic of the family was also seen as relevant to the learning, providing the authors with an insight into family life and the professional encounters. Participation by the family revealed fresh insights into the child’s life, previously unknown to agencies. Families could explain how services were delivered and what professionals did, and did not provide. For those reviewing the case any internal management reports usually only described what was done, and this limited the knowledge available:

‘Without family participation we are only seeing it through the eyes of professionals and that is not good enough to obtain maximum learning; the family’s perspective is as valid as the professionals’. It gives us the full picture and how it was for the family.’

‘Only by hearing it directly from them can we obtain the truest reflection of their perception of what happened and of their views on the services they received. No matter how well the agencies feel they know the family, nothing can make up for what the family says directly to us; what they think, what they saw, what they heard.’

‘It enriches the analysis . . . and your understanding.’

‘In a long-term neglect case, with the children on and off Child Protection Plans and a large number of professionals involved over many years, when the mother was interviewed she could not remember what happened ‘They took over’. This perspective could not have been gained from case records.’

The insights provided by family participation were demonstrated in case descriptions and it was suggested that family information had impacted directly on report conclusions and outcomes. Participants provided examples of family contributions that shed important light on professional interventions:

‘Social workers and Police Officers never talked to us in any depth or on our own; just a casual “Are you ok?”. If they had talked to us in any depth or asked specific questions, we could and would have disclosed the extent of the neglect.’

‘You never checked the food cupboards; the house was only cleaned up when there was an appointed visit.’

(Comments from two teenage survivors of long-term neglect).

The following quotes were provided by a lead review professional from a very supportive neighbour who emerged during the review but had not originally been identified during the supervision of the case:

‘I knew he was visiting.’

‘I knew where they were hiding but you didn’t ask me.’

There was a strong consensus amongst our interviewees that family participation should be given a high priority and significant weight. Many respondents described the impact of family participation very positively:

‘It’s so powerful; it still resonates months later.’

‘It’s the only source of this information; the insider’s view.’

‘It’s the most powerful influence on the whole exercise; they hold the key.’

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An altruistic and cathartic element

Whilst professionals recognised that this was not an overt or explicit purpose of family participation, there was a sense that family involvement in the review might be the first time that anyone had sat down with the family to talk about the incident, to share the facts and to put the jigsaw together. As a result of this process the review could help families cope with their feelings and the aftermath. In part this might be because the review was the only opportunity for the family to reflect on what had happened, to an independent person.

However, there was a clear understanding that the review could not be a process of therapy or support for the family:

‘That belongs somewhere else in the system.’

There was also a suggestion that participation was an active demonstration of the ethics and practices of the review process itself. Specifically, by involving the family the message was given that the review was being taken seriously and that it was being treated carefully and individually. Family involvement was presented as important in helping families to understand the process and outcomes and could support families to identify a sense of a positive outcome from a negative or tragic event.

The value of family participation is multifaceted. Professionals articulated a number of common reflections about why families should, and could, participate in the review. Ultimately family participation was argued to provide a response to unanswered questions and to move the analysis away from internal professional information towards capturing and better understanding the complex dynamics leading to the events that necessitated the review.

Whilst it was acknowledged that the purpose of the review was different for family members and reviewers, a contributor usefully summarised by saying that the purposes could be divided into two levels:

To gain the family’s perspective: to add information, clarification and a wider perspective to the review process, particularly to learn about the child and what had happened, to aid professional understanding, to ensure optimum learning about what services work and don’t work and what improvements in practice and services are needed. The family’s right to be kept informed, have their voices heard and have some influence in the decision making.

4.3 What weight should be given to securing family participation?

Words and phrases were repeatedly used that suggested that significant weight should be given to securing family participation. Participants talked about family involvement as ‘essential’, ‘a high priority’. However, it was acknowledged that some family members and significant others did not want to participate, and in some cases were afraid to become involved because of their involvement in events leading up to the review or the implications for the surviving family members. Other respondents suggested that it was “important but qualified”; and others said that it was important not to give partial views undue weight unless they were triangulated with other views. Many respondents suggested it was dependant on the individual case. Making decisions about family involvement on a case by case basis was a theme running through the data.

4.4 Who should be involved?

Respondents adopted an inclusionary approach to eligibility, using a starting point that there was no one who was ineligible per se, eg. foster carers, extended family, friends, etc. Interesting case examples were offered as illustrative of the value of wide inclusion criteria:

• a neighbour who had repeatedly contacted agencies to report suspected abuse and subsequently provided unique insights for the review • an employer of an isolated and vulnerable young man; the employer generated a culture of care amongst his employees and was able to give new insights and reflections to the review based on their unique knowledge of him.

There was a note of caution in not spreading the net too wide and ensuring that the primary purpose was kept in mind. Engaging with ‘significant others’ could not be justified on the grounds of ‘a fishing trip’ or ‘just because it might be interesting,’ the decision and threshold needed to be the analysis of potential contribution to the learning. Moreover, interviewing significant others could not prejudice other processes.

The analysis indicated that Boards/Committees and Overview Panels consciously or unconsciously distinguish between “innocent and non-culpable” parents, and those who have some responsibility for the abuse. This is most evident in extra-familial abuse. This factor was particularly evident in the consideration of whether the review would offer a perpetrator an opportunity to participate. The prevailing approach was that a review would include such an individual, on the basis that the perpetrator may well provide extremely valuable insights into the circumstances, the context and the experience of the services. However, two Boards were very clear and strong in not offering participation in these circumstances:

‘We don’t and would not interview perpetrators.’

‘Perpetrators have less rights to influence the Serious Case Review.’

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The analysis indicated that there were three caveats to be taken into account when exploring who should participate:

• A duty of care in the context of, for instance, vulnerability and mental health issues and it must be established that an interview process would not cause harm or fuel further instability. One interviewee suggested that there was value in carrying out a risk assessment to ascertain that the process of participation would not place families or agencies at greater risk.• Great sensitivity was needed if interviewing different members of the family who may be in considerable conflict with each other: the dynamics will inevitably be very raw.• Very careful consideration was needed when involving children. Some respondents noted that the review was not a therapeutic process and may not be helpful to children and young people, indeed without careful preparation the process could be harmful:

‘Children can give valuable information but a direct conversation with the author might be problematic as it could open traumatic memories; an imaginative approach can be taken by tasking professionals who are carrying out direct work with children to include relevant questions within their regular sessions.’

There was evidence of practices emerging concerned with children’s participation. Examples were provided of counsellors who were commissioned to work with a young person victim and to be “the voice of the child” in contributing to the review, of drama students enacting the child’s voice for the reviewers and of key familiar professionals eliciting the child’s views.

A further, fourth caveat emerged from the consultation events. In a time of austerity there may be a budgetary limit imposed by the LSCB on the number of interviews which could be agreed and achieved. Review authors were being limited, in some areas, in terms of the number of family members they could interview or seek to involve.

4.5 Implications for practice

Family Involvement in new approaches

This research has taken place alongside new developments in the methodology of serious case reviews; notably the SCIE developments (Fish et al 2008, Munro 2011). In our analysis of the early guidance produced by SCIE, and confirmed in an interview with a lead reviewer in the early stages of our research, family participation was not an integral part of the processes and there was very limited experience. However, as the pilot areas have expanded and more cases have been reviewed, this approach has been developed:

‘Now the SCIE model assumes that you will involve the family and this may include the subject/surviving child, not just the immediate family; wider family and significant others.’

‘Try to get them (families) onboard, i.e. involved in the planning, written and verbal information given to the family, preparation, managing their expectations, culminating in the conversation.’

‘Keep them (families) up to speed throughout and before the report is signed off it will be shared with them face to face.’

It is too early to comment on the implementation of this model for reviews rather than complex cases (an evaluation is underway but not yet concluded). We were unable to gain access to families who had participated in the SCIE model and as such only general reflections can be drawn upon when considering family involvement in the new models.

Meeting differing expectations/needs

The fieldwork for this research has confirmed that the purposes, motives and drivers for family participation will be very different for each of the contributors:

• parents• extended and wider family• children• significant others• professionals• the Review Panel• the Boards/Committees

The challenge for practice is to address and deal appropriately with these different constituencies. The data suggested a consequence of differing expectations was that there may be very real differences in perceptions and responses between those members of the ‘responsible’ side of the family and those members in the ‘non-responsible’ side of the family (i.e. responsible for the incidents of child abuse or neglect). Some family members and significant others may not come out of this process well-regarded and family members must understand the limitations of the review process. The focus remains on a professional learning agenda and it is not intended to right the wrongs, nor is it a process designed to offer advocacy and mediation. Acknowledging differing perceptions and experiences should be explicit throughout the review process, but participants recognised that the review was unlikely to achieve reconciliation in these difficult circumstances.

Hindrances and barriers to family participation


• Practitioners and their agencies could be over-protective of their own profiles and credibility; in part this was defensive behaviour. Experience indicated, because of fears about blame and criticism, agencies and their staff might discredit the validity of family participation by phrases such as:

‘They have their own agenda’ ‘They have made a complaint’ ‘It’s the wrong time’ ‘It’s too difficult to trace them.’

• Boards and Review Panels could be fearful of the responsibility of the raw emotions generated; and could also be anxious that the process would generate harm and turbulence. There was also cynicism because participation was driven by external expectations; and the potential that this resulted in a lack of commitment. We heard that some Boards and Panels feared that by encouraging family participation the resulting conclusions and recommendations might be over-influenced by the family and learning may be negatively influenced by the process of family participation. There was also the risk of the family contacting the media and a sense of wanting to ensure some professional protection in the process.

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• The families and significant others may have refused to participate based on their previous negative experiences of professionals; their acquired lack of trust in systems and people; and their suspicion that there would be a managed outcome with any conclusions or recommendations making little difference. They may also have been advised by their legal representative against participation.• Our evidence is that very often a rationale for the decision to not offer opportunities for family participation are concurrent legal proceedings. In general our interviewees confirmed that seeing family members pre-trial is possible; it is a matter of timing and negotiation with CPS/Police/lawyers. Many of our interviewees also confirmed that Boards/Authors will always try to find a way through and that the Police and CPS are generally helpful in this matter.

The publication of the full Overview Report

The decision was made by the English Coalition Government to introduce full publication of overview reports together with the executive summaries unless there are compelling reasons relating to the welfare of any children concerned in the case why this should not happen (Loughton, 2010). This raises important ethical dilemmas between (on the one hand) the public good and the public’s right to hold state organisations to account, set against (on the other hand) private rights and privacy. Indeed, should families have the right to object to publication, even of the Executive Summary?

This is a topic which emerged during all our interviews and discussions, although it had not been part of the original research questions. It is a topic which generated very strong views and feelings:

‘It has become a nightmare.’

‘The families suffer a lot of anxiety about publication; even anonymised, the Executive Summary is recognisable to the local media.’

‘They should have the right to their own information and whether or not it is published.’ There was a consensus of opinion amongst our interviewees that family information needed some moderation:

‘Learning cannot be at the expense of the well-being of surviving family members.’

‘Intimate details of for example gynaecological history, mental health issues, sexual behaviour, etc. are far too personal and could have a huge impact and be very distressing/damaging for surviving children, grandparents, etc. These should not be in the public domain.’

‘It’s bad enough that children have been abused without survivors being re-victimised by public disclosure of their case.’

For some professionals, when redaction was taken to an extreme in order to protect the family, the risk was of the report becoming a meaningless document which defeated the objective. There also a danger that the process results in partial reports and fuller accounts being shared informally.

Examples were provided of negotiated processes in respect of publication. One LSCB had sought the opinion of a child psychiatrist, who subsequently recommended that it would not be in the child’s interest to publish. The LSCB’s decision not to publish had been supported and accepted by Ofsted and by the Department for Education in England.

We were alerted to the implications of a ‘media-fest’ and the impracticality of trying to maintain anonymity in small communities. This required that Boards and Overview Report Chairs/Authors be painfully honest with families, explaining that their protection could not be guaranteed. The management of the media was a challenging reality; and we also learned of the crucial role politicians could play in this regard, with an example of experience in Scotland where negotiations were helped by political interventions.

A guiding principle was suggested from one consultation event:

‘The material from the Serious Case Review which is placed in the public domain should not add to what is already in the public domain from the criminal or coronial processes.’

In summary, all responses indicated that publication was problematic and that frequently the disadvantages outweighed the benefits. A theme emerged of approaches that sought to question when and why publication would be useful and a sense that change could be achieved without publication. Indeed there was also some sense that undertaking a serious case was being avoided, where possible, because of the difficulties posed by publication.

Independence of the review process

At one level this may appear to be a somewhat esoteric and theoretical issue, but our research identified it as an important issue for families; issues of independence could be crucial in giving families confidence that the conduct and outcome of the review would be objective; not least, because Safeguarding Boards struggled to promote themselves as independent of the local authority in general and of children’s services in particular.

Respondents did note that it was important to make clear to the family that the Independent Chair/Author is not part of the LSCB; but, as will be noted in Section 5 of this report, families talked of the calibre of the Chair/Author being potentially more important than their independent status. There was a view that families must not be misled in any way about the nature of the independence. The Board/Committee commissioned the review and therefore there was a widespread belief that the Board ‘owns’ the report and has the responsibility to evaluate the quality of the report. Ultimately, any dispute resolution may need to involve Ofsted (England), the Welsh Inspectorate, and overseeing authorities for Northern Ireland and Scotland respectively.

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In some smaller local authority areas and provinces there was greater difficulty in securing complete independence as the professional communities were very familiar with each other:

‘In reality, a lot of Boards commission someone they know . . . and there will be an understanding and working relationship between them that helps to reduce tension.’

Ways of managing tensions of ownership and independence were offered in the consultation events and included:

• Setting tight Terms of Reference and ironing out tensions at the early stages• Having a protocol that provided guidance on managing disagreements• Having a robust process to avoid tension when the report is presented to the Committee/Board, and untangling disagreements before the report is presented• More training in report writing and family involvement.

As evidence has demonstrated attention and thought has been given to family involvement by professionals at local and practice levels. There are, however, complex challenges and opportunities that arise, and some difficult dilemmas are being posed.

SECTION 5: FAMILY EXPERIENCES OF REVIEWS5.1 The Families

The study, from the outset, sought to ensure family voices were fore grounded in the research process and the final reports. In part this was to address the absence of family voices in the published literature on case reviews, but also to maximise the learning presented by the design of the study. There are well acknowledged challenges in accessing vulnerable and marginalised families (Munro et al 2008). Reaching families who had participated in a review following the death or serious injury of a child was extremely difficult. There were multiple and complex reasons for these difficulties, not least societal responses to families where a child has died, and the media and public interest families had experienced resulting in aversion to further exposure.

There was also professional reluctance to inviting families to participate in the research. Concerns included; destabilising current interventions, generating emotions that would be unhelpful, ownership of the information the researchers gathered from families and views that previous non co-operation effectively disbarred families from participation in the research. Nevertheless, some Boards and some professionals did make considerable efforts to facilitate access for the researchers to families, and some families made direct contact with the research project without any professional mediation.

The cohort of families participating in the research was not a representative sample of all families who have contributed to case reviews; a robust sampling strategy could not be adopted in circumstances where identification and access was so difficult. Instead, the research team conducted interviews with all those families willing to participate. Involvement in a case review was the only pre requisite for participation; beyond this the study did not have any inclusion or exclusion criteria. There was a process of piloting the research design with one family, and the data gathered from this formative process was incorporated into the final analysis.

Once contact was made with families by the research team, all those approached agreed to be interviewed, and shared at length with the researchers their experiences. The sample of adults and young people from seven families and two family representatives was too small to draw out any substantive, general conclusions. Instead, the family narratives provided insights into the experience of participation and raised questions that can inform and support the development of policy and practice. The analysis of the data from families used a process of coding and categorisation, working up from the data to arrive at themes and, ultimately, messages for practice.

Following the initial analysis, families had the opportunity to review and amend the drafts of the report, ensuring some internal verification of the initial analysis. The families were assured of their anonymity in the outputs from the research and consequently no identifying information about the sample is provided. The serious and sometimes public nature of the events that led to the reviews meant that careful attention had to be paid to rendering the family data anonymous.

The participants included adults and young people, and various members of family networks (grandparents, adult siblings, parents, extended family members).

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All the families had experienced significant engagement with protective services, some more recently than others. Quotes are used from family members to illustrate the analysis of the family data but care has been taken to ensure that unintended identification is not possible.

The analysis indicated that family narratives could be organised using common stages in their experiences. Families did not have uniform experiences at each stage and the services and practices adopted by individual professionals and agencies varied, but the family accounts could be grouped using the following stages of engagement:

• the aftermath of the events leading to the review • the drivers for their participation • the process of participation• the impact of the review • family reflections on the skills and practices necessary to support involvement.

5.2 The Initial Stages of the Review Process

The services and practices that were delivered immediately after the critical incident that necessitated the review were uniformly experienced by families as confusing and difficult to comprehend. All the families described being overwhelmed by the professional responses, unclear about the roles and responsibilities of the professionals and the processes they encountered. The families were aware of underlying professional anxieties about risk to reputational credibility and professional identity, and some family members understood this anxiety to be detrimental to the practitioners’ ability to respond appropriately to the families’ experiences and needs. Families were often mistrustful of professional agendas and responses:

‘you just need to build that trust within the family so the local authority needs to understand that we need to build that trust within the family before even involving them within the process, they need to understand what constitutes the family around the child, they need to understand if there are issues around culture and religion or faith involved, they need to understand that because by having a level of understanding of these issues around family it helps you, or it assists the local authority, also the report, to better work with this family and to get the most out of the family within the process.’

What was experienced as poor, chaotic practice at this time often mirrored for families preceding experiences of professional interventions. There was a sense amongst some family members that the services struggled prior to the critical incident to provide robust, adequate services and continued to do so after the event. Families described difficult encounters with professionals after the critical incidents and in the initial stages of the review, describing what they perceived to be careless and insensitive practices:

‘... so this is only a month later, he said that they hand delivered a letter to XXX and they declined, well I tell you... I wrote back……..Yeah. I sent a letter back saying I actually can’t believe, I actually can’t believe your approach and I actually felt as though I had to try and bring him to a level to come out from behind his desk and to actually acknowledge (the loss) just a very, very basic simple thing in my mind, bearing in mind how professional these people are…’

‘I mean in my eyes you never, ever say to somebody who’s suffered domestic abuse, whatever level, theirs was at the very worst end, that why didn’t you get out? It’s almost a basic level of communication, and I mean thereafter, I said it’s alright having all these DV courses for frontline staff and the psychology of DV, what about the people who are sitting on the boards and sitting on the desks, are they not... you know they make it worse...’

Families’ frustration at the overwhelming level of activity after the event rather than before made engagement difficult, for some a sense of services providing ‘too much too late’ resulted in bitterness and anger (which subsequently fed into their responses when participating in the review). This family analysis of poor practice was then reinforced by a feeling that their loss was unacknowledged or unappreciated. Skilled practice was required and when encountered was particularly appreciated:

‘I think they did see us as a family you know, a family that were going through stress and obviously the distress of losing my daughter and brothers and sisters and everything, a loved one. I felt they treated us with sensitivity and I think they were very approachable and you know I just got really positive, you know I just felt really positive and I mean that’s why I thanked them because to me they did, they were very sensitive, they didn’t come in sort of saying oh we are the professionals, you know they came in as human people and I think you know that’s what needs to be seen really.’

Thus, for families the quality of practice immediately after the events that led to the review was a) connected to the quality of any preceding services / practices and b) instrumental in determining their approach to participation in subsequent processes and interventions and their expectations and aspirations for the review. This indicated the value of those responsible for the review gaining insights into the family experiences in the aftermath of the critical incidents, if family involvement in the review was to be understood and facilitated:

‘Some families they might feel that it’s right for them (participation), and others might not, I mean they may have a good social worker supporting them enough and you know when it comes to the serious case review, but often it’s too late isn’t it, you know, what’s the point, you know, so what happened in the family they should have been supported in the family whenever, you know, ten years ago, you know. Whereas like you know advising the family in case reviews and everything for me it was pointless, it’s like you’re too late, you’ve come too late.’

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5.3 The Drivers for Participation

Family reasons for participating in the review varied, and as a result their experiences of the review differed. For the majority of families participation in the review was driven in part by wanting to better understand what had happened to the child and the events that led up to the critical incident(s). (Although this was not the case for those who had themselves been the subject of the review). However, for some the decision to hold a review was difficult and they felt disempowered by the absence of any influence to stop or delay the review:

‘there’s me reading the newspapers saying the local safeguarding children’s board couldn’t do anything der de der, and I sat there and I thought, I’m not standing for this, this is people... when people are put through this by the perpetrator they are also put through it by the system and they are trying to deal with real trauma, and nobody’s got a clue, and because they aren’t able to voice, because they’re dealing with survival, they’re dealing with so much that they’re not going to stand there and shake their corner, and say stop it, because they can’t do that.’

As section three discusses, professionals suggested family involvement was an important opportunity to hear more about and gain unique knowledge about the child’s life. This motive for participation was shared by families, despite many professional assumptions that the family knew what happened and why, and that the family held the detailed knowledge about the child’s life. For their part families hoped the review would provide them with information about the services and about the risks to the child. For some family members this resulted in ‘new news’ and they heard about risks or safeguarding issues for the first time. This was a complex experience for families – in gaining knowledge about the child’s life (and in some circumstances their death) family members could be left with painful feelings of guilt and culpability. This had significant implications for how information was shared and understood during the course of the review:

‘I mean you know by giving them the opportunity to explore how they want that information, because everybody is different, and maybe there’s some things that they may not want to know, because it’s like me, everything was with open arms, but somebody may not want to know that because they may find that they’re better with what they’ve got in their own head, you know, and that they’re better coping with what they think themselves, rather than opening doors what are going to lead them to more distress.’

Families who had been bewildered by the events prior to and post the critical incident wanted the review to help them understand these better, in particular why certain professional interventions occurred and the basis for professional decisions. Within the family narratives was also a desire to give voice to the child and to address what were perceived as unjust actions or approaches adopted by professionals, and in some cases by perpetrators. Families described a moral responsibility to represent the child and to seek justice for any perceived wrongdoing experienced by the child and their family. This included addressing the crimes perpetrated by the offender and / or perceived wrongful actions by the agencies. But this need for redress was tempered by an understanding that events had been complex and that identifying inappropriate or harmful activity was not a straightforward process:

‘Since then I’m understanding this no blame philosophy, the difficulty I’m having is I’m hearing people say we must have accountability, but we shouldn’t engender a blame type environment, I agree with that, I feel that we are more likely to have meaningful reviews if people feel that they can be creative and they can disclose things, however, I get confused in my own head and I don’t have a satisfactory answer to this yet, what is the difference between blame and accountability apart from the spelling?’

For families, taking part in the review was sometimes driven by a desire to find resolution and repair. The events surrounding the injury or death of the child were traumatic and profoundly painful. They hoped that the review might help assist them in moving forward with their lives. Repair in this context was a difficult motivation for participation. The extent to which a review could meet these family needs was limited, with the professional agendas concerned with learning and change not always sitting comfortably with family expectations about emotional resolution.

‘Professionals don’t grieve like the family do; they just move onto the next case, going from one job to another; for the family it stays forever.’

For all those interviewed securing changes in processes and practices so that future similar episodes of injury and harm could be prevented was a prime reason for participation. For families the role of the review in promoting and supporting change to prevent further trauma and loss for other families was a key impetus for participation – whatever the circumstances leading to the death or injury of the child. Family expected change to occur as a result of the review and this incentive to be involved had significant implications for family responses to how they were made aware of and understood any changes arising from the review:

‘it was obvious there was something broken in the system and we cannot walk away without knowing we’ve made efforts to fix it, and see it fixed.’

In summary, family narratives suggested that the drivers for their participation included:


5.4 The Process of Participation

Whilst there are a limited number of common experiences in the narratives, all families reported confusion about the role and purpose of the review when the case review was initially discussed with them. Families were often at this stage dealing with multiple processes and procedures.

These included care proceedings, criminal proceedings, inquests, child protection processes and various health and medical procedures / interventions. For families, navigating their way through what was experienced as a bewildering array of professional activity proved to be very difficult. This experience was compounded by any family uneasiness about the quality and focus of practice after the child had died or sustained

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severe injury / neglect. For some family members it was only some time after the review that they were able to fully comprehend its purpose and functions:

‘ I think because I was so wrapped up with my baby and my life I don’t really have a clear picture of okay this is how it happened. People were all just coming at me and they were all just saying things and it just seemed like an ongoing process, everything was up in the air, and just, and so looking back I’m like okay could I tell you... it was almost like a story, like a dream, I know it was real, I know it happened, but it feels, I was so wrapped up, so panicky, so emotional with what happened, it becomes hard then for me to say, oh okay yes, so I knew there was a serious case review because such and such, and things like reading the information, I couldn’t even do that. It was only when everything was over that I finally was at a place where I could do it and looking back I was like oh okay so that was why, but it was too late…’

This expression of confusion was common. Navigating this complex territory of procedures was difficult and at times inhibited family engagement in the review process. It was evident that explanations about the role of the review and clarity about the relationship to other processes required careful discussion, and assisting families in gaining a comprehensive understanding of the multiple processes was linked to building their capacity to participate. For families understanding the procedures that at times overlapped in their expectations and demands was challenging and exhausting. The difference in purpose and responsibilities between the review and the other processes was unclear, and families were therefore confused about how to engage and what information to share with whom and when. For some, notification of the review came relatively late and they felt enormous frustration at being excluded and having to seek out ways to contribute.

‘I mean that’s where they needed somebody like that, and then if something like a letter come or whatever, that person could have explained it.…or even gone with them wherever they had to go, different places been with them, because that’s what they needed, not me, or someone in the family, because we don’t what the hell’s going on do we, and plus what’s happened....but there wasn’t, they had nothing like that.’

Alongside the uncertainty about professional activity were anxieties about the timing of the review alongside other processes. For some families the review came at a time when they felt they were least able to participate.

‘Can I mention here that one of the biggest hurdles I felt is agencies not being aware of where the family may be at in terms of engagement with other agencies….. to give our example of the production of the SCR at the end of the court case where it appeared to me the judge and the LSCB were NOT aware my family had not been granted permission to bury our child?’

For others, timing was not problematic and was negotiated in such a way by professionals that the family felt they gained enhanced insights as a result of the professional timelines for the processes. Families had been provided with a clear rationale for the timelines and were able to understand how the agreed plan of activity would support the resulting learning.

Once families had agreed to participate the most common experience was an opportunity to meet with the review author and / or the chair of the review. Some families described simply receiving a letter informing them of the review but others were able to describe practices that helped prepare them for sharing their information. There were concerns about who constituted the family – with some extended family members finding it difficult at times to become involved in the review. This did vary; some family members experienced a process of consultation about who the review should involve, and others felt shut out of the review despite having directly relevant knowledge and information:

‘…what’s the point, because they don’t want to know what your side of it is, whether you be a surviving victim or a grandmother, or an uncle, they don’t seem to want that angle, it’s almost as though ‘we are the experts, we know what should happen’.’

The extent to which families felt able to exercise any influence over the process of the review and the terms of engagement varied. Examples of extensive consultation about the process were given, and these experiences were valued. In such circumstances families felt they were supported to participate and could understand how their contribution was to be used in the process.

‘…. it was more at the end, they came to tell me that they were ready to... they had compiled all their evidence and the information and everything, and so they made an appointment... Maybe people would think well I would like to know in the interim you know, I’d like to be told little bits, but you know how can they provide a big picture if they haven’t got all the information, so if it took that time it took that time, but at least they was able then to come to me to say you know this is everything, and then provide that picture, rather than give me little snippets, and then still me thinking well what about this, what about this and this, and again they wouldn’t be able to give me that information because maybe they’ve not gathered that information yet. So I don’t know, to me it was better the way it was done, it worked better for me than it would be to be giving me little bits of information along the way, because that little bit of information may have provided me with more questions……’ The facilitation of family contributions was demanding. Families valued those professionals that engaged with the emotion of the experiences and recognised their loss and trauma. One off visits (where information was given without any preparation before or after the interview) or inappropriate practices, were remembered critically. The independence of those engaged in leading the review was important to families, in particular how this independence was evidenced:

‘I’m beginning to wonder if an independence is achieved by the calibre….. by the calibre of the individual rather than the office they hold.’

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The scope for families to debate the accuracy of the content and the learning arrived at by the review was variable. Some family members experienced the final outputs as beneficial in helping them arrive at a fuller understanding of events and the child’s life. They also recognised the potential for changes that might avert future tragedies. For others the opportunity to correct content or register a minority view was limited, not least by only having access to the executive summary: ‘I remember that report because there was something that was written that just wasn’t true, and I remember they talked about something like the xxx, and we’d never met her, we’d seen her once, and they said she’d been coming regularly to the house, which was just rubbish, and I was quite angry about what they’d written, and I felt that they were sort of adding bits to suit, so I wanted to see what they’d written exactly, because I don’t know if that was the report… but whatever it was I wanted to know what had been put in and I wanted to know what they’d written and why. ‘

‘So I don’t think that families necessarily know opportunities out there to have more information disclosed, or negotiated processes, there’s probably no manual which says there will be a negotiated process, I still think there will be deference amongst many persons to authority, we go along to this review, we say what we say and we go away.’

In drawing together family experiences, the analysis suggested a number of themes arising from the process of participation in a review:

• A confusion about the relationship between different procedures and the remit of each process• A tension between process adherence when set against the responsivity needed to address family trauma and loss• The process by which the ‘rules of engagement’ and the focus of involvement (who / how) are decided, and the family role in this activity • The need for practice that engaged with the emotion of the situation and family experiences• Taking care and careful practice, including how family information was used and how accuracy was ensured.

5.5 The Impact of the Review

For some family members the experience of contributing to a review was recent and still very fresh in their minds, for others the review had occurred some time ago (for some a number of years ago) and they benefitted from the opportunity to consider the process and experience retrospectively. The impact of the review was linked to arrangements for understanding any sustained, long term change. Without knowledge of any lasting change families felt their participation to have been of limited worth:

‘….you want to go somewhere and you want to see what the action plan is, how far through it is, now what were the recommendations, how far through are they, what are the times, you know you must have a timetable surely.’

In reality, for family members concerns about limited knowledge of change may arise as a result of professionals not communicating changes rather than change not occurring. The restricted degree to which agencies fed back their change plans after the review meant families could experience the review as fruitless, irrespective of any actual changes in policies and practice. Family members rarely had ongoing contact with those leading the review and so were unable to describe changes arising from the learning contained in the review. The family members that had been kept in touch with the implementation of action plans were positive about this experience and found it helped validate their participation and provided some assurances for the future:

‘I felt very comfortable and as well the nice thing was as well they said you know if you’ve got any questions please get in touch with us, you know, so if there was anything that I sort of felt as an aftermath, oh I didn’t ask about this, that I could have quite easily have rung, made contact...’

For families the sharing of intimate details about their lives and the child’s life did not always result in the formal recognition they anticipated. Specifically, family members expected that their narrative would form a significant part of the final outputs from the review. Family descriptions indicated that review authors were not always clear how they intended to use the personal accounts that were shared, and as a result family members felt disrespected:

‘….in future people writing reports should listen to the person that’s talking to them, it’s rude not to listen to them. I knew I hadn’t been listened to because the report didn’t include all the information…..they didn’t include what I’d told them…….’

The practice by those leading the review to gather detailed information about the family and the child in order to arrive the learning for future policies and practices required careful explanation in order for families to feel their lives had not been dismissed or disregarded. The personal and intimate details of their lives were edited or selectively used in reports, but families had anticipated a fuller account. There is, however, a set of tensions here in terms of disclosure and access. Family members had shared information that they did not want other family members to read, and / or did not want in the public domain. Furthermore, families wanted to be able to access the full review report, but did not necessarily want this to be published. Family members suggested that family access needed to be privileged, with agreements reached to enable family members to read reports but with restricted public access. This would not resolve the difficulties posed by family members making contributions on the basis of restricted access by other family members to the information. The challenge facing report authors was to produce outputs that worked within these difficult and at times contradictory positions on access.

On occasion families saw publication to be important in raising awareness about specific risks or to promoting particular changes. In some circumstances publication was presented as a necessary step for holding agencies to account and achieving transparency:

‘But because it was only the Executive Summary and I couldn’t see the full Report, it didn’t answer my questions; it didn’t explain the reasons for the tragedy; because I couldn’t get the whole information, therefore, I didn’t understand what had really happened. You need to see the full report to regain trust and confidence.’

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But for most family members the possibility of publication posed a risk of identification. Many had had tense encounters with the media and saw publication as reinforcing the difficulties they faced. None saw publication as possible without their identity becoming known. There were concerns about individual family members already traumatised having to deal with public curiosity and judgement; they also felt that publication might heighten emotional or physical risk to surviving family members.

For families the events leading to the review and the experiences since the review had been complex and difficult and continued to reverberate. They were aware that for professionals the review was an ‘event’ with a start and finish, but this was not their reality. Families had continued to deal with painful and traumatic experiences, and thus the review for some served a limited purpose in relation to their needs for resolution and change. The quality of any ongoing relationship with those connected to the review was linked to this sense of professionals either ‘moving on’ or being supportive. For some families the opportunity to remain in contact with representatives of the relevant safeguarding boards and to be able to hear about subsequent changes was important in the process of repairing their lives. For others, there had been no ongoing contact and the frustrations about the services they received, or were still receiving remained:

‘…there’s a level of trauma whatever way you look at it, but all the different processes that you have to engage in and the way you are dealt with has to take all of that into account, and that’s definitely not happening, and even when you try and engage with you know the local safeguarding board, whoever it is, if you feel as though you know, they’re obviously not there, they don’t understand.’

The legacy of participating in the review for families was varied. Some experienced the review as a vehicle for change and some resolution was reached, even when sense of profound loss continued. For others the review was a source of bitterness and anger, with outstanding issues unresolved. The family narratives were informed by their assessment of the quality of the review process, and the original reasons leading to the review. There were invariably issues of guilt, blame and anger still reverberating from the events that led to the review. Whilst the experiences were diverse, thematically the experiences that influenced the impact of the review on families can be summarised as:


5.6 The Skills and Practices Required

Families talked at length about the skills and practices of those professionals who had undertaken the review. Well developed interpersonal skills were valued, and were described in some detail. The initial point of contact was set out as instrumental in subsequently engaging the family:

‘I think that’s the most important bit, I think the introduction is the most important bit because that can be instant, that is an instant, you know, it will either work or won’t work…..And I think that’s the most important bit, if you get that bit right I think you’ve got a start.’

‘...they’re prepared as well …. if you’re to say to them about the serious case review and then maybe leave them with that and then go back at a different time or contact them at a different time because I think as well sometimes, especially when people are very stressed they’re so overwhelmed with all the information that sometimes things can get confused, and there’s so many people on board that they get inundated, and I think by just sort of going and giving them a short brief, or even a letter just explaining what the serious case review is, or a simple booklet, or something, that will allow them to sit there at their own pace to read that, so that in preparation of somebody going to see them that they are prepared and they’re ready for what the person’s... and they’ve already taken in what that person and what the serious case review’s about, rather than maybe saying this is a serious case review, der de der de der, and you know we’re going to give you all this information, I think it gives the opportunity for that person to work out how much they do want to know, and what part they want to play in it.’

Skills in communication and in recognising and working with the families’ trauma and loss were valued. Families anticipated someone in the role of leading the review would have significant relevant experience and wanted to see this knowledge translated into the practices they experienced:

‘I talk about having imaginative, creative people,……I’m thinking please, please come to the table and believe that you can do something, you know, think about it. You’re being given this story of a human being who’s no longer here, it’s so important that you take that really seriously and you know it may be that you don’t achieve anything, but let’s give it the best possible chance.’

‘I mean how does people who input into serious case reviews, what training do they receive, do they have families who have been throughout serious case reviews to help them with their training?’

Building a rapport allowed family members to feel comfortable in sharing their information, and ensured additional distress was not an outcome of participation. The report author and those leading the review had a key role in developing this working relationship:

‘Yes, I think what they have to do is almost put themselves into that position, I know they say….that you have to keep some form of detachment to enable you to work, but I think when you’re actually dealing with that person you almost have to be part of it, you have to feel what they’re feeling, and you know, I understand about being detached, but I think that it’s so important to share almost in their grief because that way then you’re not going

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to say the wrong thing because you know little things can just make you feel so bad, and it may just be something so simple that somebody may say to you that you then think, or it could be twisted and you would think well hang on a minute, why did that person say that? And then the defence comes up and then you’re probably not going to get... you’ve probably lost all the hard work that you’ve done with that person and probably the time that it’s taken to build up that rapport with them and work with them, and then suddenly because of one sentence that you’ve said...’

Families described the value of having someone to help them navigate their way through the review process. This became particularly pressing when families did not share a common language with the professionals and required translators and interpreters. For some families the skills of professionals in using interpreters raised particular concerns. Families who felt marginalised from mainstream provision felt the review process potentially further alienated them:

‘I just felt I wanted them to have a bit more awareness, to have training….to have more kind of interaction, more of a rapport with us, to understand where we were coming from, who we are, our background, just take more time with it, and to realise where we’re from, and we didn’t have any of that, there was just here’s a visit, we’re the professionals you know……’

In part issues about interpreters and specific barriers to participation were representative of a pervasive sense that professionals needed to demonstrate care in their encounters with families. Families wanted professionals to have gathered all relevant details so they did not meet the family unaware of key issues (for example dates of birthdays, funeral arrangements, ongoing medical needs and any needs arising from language, disability or ill health). Careful mapping of the extended family and their relevance to the child’s life was also expected. Professionals that paid attention to important details and whose practice included what might be small but symbolic gestures were valued, even when the events were overwhelming and tragic:

‘...you know, like even the police officer, my washer blew up on the day, and blew up into flames, and that was before I even knew that she’d died and so I had no washer, I was then told, so the last thing on my mind was the washer or the washing, well she (the family liaison officer) left here with two big swag bags of washing and she took them home, and came back, all the washing done, ironed, everything.’

The nature of any ongoing links into the processes for achieving change was a recurrent theme, evident in the extent to which the family judgements of the quality of practice were associated with their access to ongoing information about professional learning:

‘Yeah, you know, because we can’t... and at the end of the day I think everybody will agree that okay you don’t have to put social workers names in, you don’t have to identify people, you don’t have to give a medical notes on people, none of that is correct, but there is a level of what people need to access if they want to, and I think a family should be treated differently to public, even if you sign a form to say I will not release... this is confidential, an affidavit.’

Family members repeatedly expressed a wish to see the full report and to hear about agency actions plans. This was partly connected to securing a level of accountability for errors and for subsequent change, but also to affirm for the family that their involvement had had value and worth. Some families had remained in contact with agencies, and they had appreciated the attempts by the agencies to keep them informed of changes. Not all families wanted this ongoing involvement, for some the pain of the events leading to the review meant ongoing contact was too traumatic. Careful negotiations about these arrangements were clearly necessary – and arrangements varied between families.

Drawing together the family narratives, the skills and practices that were valued and facilitated participation included:


5.7 Summary

Families’ experiences of involvement were not uniform, nor were their aspirations or expectations. The trauma of their experiences demanded skilful sophisticated practice, but evidence of this was uneven. Families expected to see a connection between their contributions and the change process; they also had multiple reasons for their decision to participate in the review. Managing family expectations and dealing sensitively with their needs was a considerable practice challenge for those engaged in the review processes.

The family narratives indicated a number of areas that merit further examination:

• An extended study of family experiences - the voices of families in developing policy and practice in this complex area are rarely heard. This study suggests that there is a great deal of learning about services, protection and safety and effective interventions to be gained from an extended study of family experiences and contributions. • An examination of the role of children and young people in reviews. Our study raised questions about the practices and policies needed to facilitate their involvement. It also raised questions about the feasibility and appropriateness of involvement in different situations. The young people who contributed to this study had very clear views - extending this sample and therefore extending the learning would benefit future practice development.• This study focused on those cases that met the highest threshold for case reviews, but we are aware of models being piloted that are exploring learning in difficult cases but below the serious review threshold (for example the SCIE model). Examining family involvement in these reviews (where the level of trauma, grief and loss may be less intense) may hold useful learning for family engagement more generally.

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RESEARCH SUMMARY AND PRACTICE RECOMMENDATIONS

6. INVOLVING FAMILIES IN CASE REVIEWS: RESEARCH SUMMARY AND PRACTICE RECOMMENDATIONS 6.1 SUMMARY OF THE RESEARCH

6.1.1 The Study

The UK policy expectations for family involvement in case reviews have not been matched by allied developments in practice guidance. The study set out to address the following questions:

• What are the current arrangements for participation as set out in local protocols and procedures in England, Northern Ireland, Wales and Scotland? • What are the experiences of families who have participated in reviews and what learning can be drawn from these experiences? • What are the professional experiences of family involvement? • What conclusions can be drawn for guiding effective practice?

The research was reviewed and approved by the University of Nottingham research ethics procedures and careful safeguarding arrangements were adopted. The study consisted of five, interlinked stages:

1. A review of all published guidance across the four UK countries 2. An initial series of expert focus groups that supported the fieldwork design 3. Telephone interviews with policy makers / practitioners with particular expertise 4. Interviews with family members who had participated in case reviews 5. A final series of consultation events across the four countries.

6.1.2 Professional Experiences

The purposes of family involvement: four themes emerged from the study:

A rights perspective: Professionals argued that for parents and close family members involvement was a rights-based issue. Participants identified an analogy to the development of family participation in Child Protection Conferences, which also addressed issues of rights and responsibilities. Good practice: a child-centred perspective: Professionals’ responses indicated that family involvement was the closest point when seeking to understand life through the eyes of the child. Report authors talked about specific material that the family might offer that gave the child a real identity, including, for example, photographs of the child. Such material was seen as placing the child in the centre of the process.A view that the family holds key information which will inform learning and contribute to the change process: Participation triangulates information and minimises assumptions being made based solely on case records or agency reports. Family narratives about services held key information which was unique and the dynamic of the family was also seen as relevant to the learning, providing the authors with an insight into family life and the professional encounters.

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An altruistic and cathartic element: Whilst professionals recognised that this was not an overt or explicit purpose of family participation, the review could help families cope with their feelings and the aftermath. However, there was a clear understanding that the review could not be a process of therapy or support for the family.

Who should be involved?

In almost all responses an inclusionary approach to eligibility was adopted, but there was a note of caution in not spreading the net too wide and ensuring that the primary purpose was kept in mind. The analysis indicated that there were three caveats to be taken into account when exploring who should participate:

• A duty of care in the context of, for instance, vulnerability and mental health issues • Clarity and sensitivity about antagonistic internal family relationships • Very careful consideration was needed when involving children.

A further, fourth caveat emerged from the consultation events. Review authors were being limited, in some areas, in terms of the number of family members they could interview or seek to involve because of funding restrictions. Hindrances and barriers to family participation


• Practitioners and their agencies could be over-protective of their own reputation and credibility when managing the process of participation • Boards and Review Panels could be fearful of the responsibility of the raw emotions generated; and could also be anxious that the process would generate harm and turbulence • Some families and significant others refused to participate based on their previous negative experiences of professionals• Very often a rationale for the decision to not offer opportunities for family participation is concurrent legal proceedings. In general our evidence indicated that seeing family members pre-trial was possible; it was a matter of timing and negotiation with CPS/Police/lawyers.

6.1.3 Family Experiences

The Initial Stages of the Review Process: The services and practices that were delivered immediately after the critical incident that necessitated the review were uniformly experienced by families as confusing and difficult to comprehend. The families were aware of underlying professional anxieties about risk to reputational credibility and professional identity, and some family members understood this anxiety to be detrimental to the practitioners’ ability to respond appropriately to the families’ experiences and needs.

What was experienced as poor, chaotic practice at this time often mirrored for families preceding experiences of professional interventions. Skilled practice was required and when encountered was particularly appreciated. For families the quality of practice immediately after the events that led to the review was connected to the quality of any preceding services / practices. It was instrumental in determining their approach to

participation in subsequent processes and interventions, and their expectations and aspirations for the review.

The Drivers for Participation: Family reasons for participating in the review varied, and as a result their experiences of the review differed. For all the families the role of the review in promoting and supporting change to prevent further trauma and loss for other families was a key impetus for participation – whatever the circumstances leading to the death or injury of the child. Family narratives suggested that the drivers for their participation included:


The Process of Participation: In drawing together family experiences, the analysis suggested a number of themes arising from the process of participation in a review:

• A confusion about the relationship between different procedures and the remit of each process• A tension between process adherence when set against the responsivity needed to address family trauma and loss• The process by which the ‘rules of engagement’ and the focus of involvement (who / how) are decided, and the family role in this activity • The need for practice that engaged with the emotion of the situation and family experiences• Taking care and careful practice, including how family information was used and how accuracy was ensured.

The Impact of the Review: The impact of the review was linked to arrangements for understanding any sustained, long term change. Whilst the experiences were diverse, thematically the experiences that influenced the impact of the review on families can be summarised as:


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The Skills and Practices Required: Drawing together the family narratives, the skills and practices that were valued and facilitated participation included:


6.1.4 Practice Recommendations

Whilst the research project was able to include young people and professionals who had experience of child participation in reviews, the extent of child involvement in practice was impossible to gauge and it was therefore difficult to arrive at any firm conclusions. Consequently, this set of recommendations focuses on adult involvement and further work is needed to a) understand the purpose and extent of child participation in existing practice and b) the shape and nature of best practice in children and young people’s participation in case reviews.

6.2 RECOMMENDATIONS FOR POLICY AND PRACTICE 6.2.1 Principles for Policy

The findings from this study suggest that family involvement has the potential to make an important contribution to the learning from reviews of the most serious cases of child death or serious injury arising from abuse or neglect. Each of the four nations are in the process of revising their arrangements for carrying out a review and the role for family members will need to be addressed in any new guidance. The Munro Review has been critical of the prescriptive approaches to child protection procedures and the requirements of procedural compliance that determine review processes and practices. (Munro 2011). The tendency to create guidance that is lengthier and more detailed is being curtailed. New guidance for reviews is likely to be briefer and may revert to the earlier practice of being led by principles rather than instruction. This study of family involvement suggests that guiding principles rather than prescriptive practice is well suited to the policies and practices of family participation. The evidence indicates that the principles grounded in clarity, transparency, negotiation and inclusivity can usefully inform family involvement. The research suggests the value of adopting the following principles for family involvement:

Principles for Family Involvement in Case reviews:

Clarity of purpose: the purpose of family involvement in a review process should be set out in such a way that is clear and easy to understand. There may be multiple reasons for seeking family involvement, these should be described and families should be able to discuss with the reviewers how their own particular involvement is being understood. Any scope for negotiation about the purpose from the family’s perspective should also be explained.

Transparency in limits and opportunities: clarity is needed about the level and reach of participation – families may face predetermined limits to the extent to which they can become involved, equally extensive involvement may be sought. Establishing the parameters of participation very early on in any review process is vital if families are to feel secure in their understandings of the processes and outcomes.

Negotiation: the terms of engagement for family involvement should be carefully negotiated for each review. The use of information, arrangements for confidentiality and scope for influencing outcomes must all be agreed. Non negotiable processes must also be explained.

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Inclusivity: a broad understanding of ‘family’ should be adopted. Assumptions of an inclusive approach should be made, drawing on family members who were important to the child and knew the child well, including surviving children and their siblings. Exclusion criteria that draws on the culpability of the individual may limit the learning.

Sensitivity: uniform policies are unlikely to meet the diverse participative needs of family members. Boards and review leads will need to exercise considerable professional judgement in the methods and approaches adopted to facilitate participation, including child level skills and the use of interpreters.

Evaluation: seeking feedback from family members on the process of any review will enable learning to be developed about family involvement. Such feedback can inform future training and practices.

6.2.2 Supporting Practice

The research design enabled learning for practice to be developed, alongside gaining an understanding of the challenges facing attempts to secure meaningful family involvement in case reviews. Additional consideration needs to be given to recommendations for the involvement of children and young people. Whilst the research project was able to include young people and professionals who had experience of child participation in reviews, the extent of child involvement in practice was impossible to gauge and it was therefore difficult to arrive at any firm conclusions. Consequently, this set of recommendations focuses on adult involvement and further work is needed to a) understand the purpose and extent of child participation in existing practice and b) the shape and nature of best practice in children and young people’s participation in case reviews.


The research revealed a range of reasons for family involvement in case reviews. But it also revealed that agencies rarely make clear why they seek family involvement in the review processes. The various terms adopted to describe participation (‘engagement’, ‘involvement’, ‘consultation’) suggested clarity is needed. In order for families to become involved in a manner that avoids further harm, and for professionals to be clear about their involvement, there is considerable value in local protocols being transparent about the reasons for seeking family involvement. The possible reasons might include;

a) Rights and responsibilities (understandings of human rights, expectations about family responsibilities for the child and for other children).

b) Extending knowledge (a recognition that family members may hold information that professionals do not, not least how services were experienced and understood).

c) Enhanced learning (recognition that the family hold important information about the child and their life that can uniquely inform the learning coming from the review).

d) Accountability; (families have a set of rights to know about the outcome of the review and the changes proposed).

In practice the extent to which the review process meets family needs will vary – but any family participation should be agreed on the basis of the review as a learning process, not as a therapeutic aid. Families will need careful guidance in this area and expectations about repair and resolution must be carefully managed.


To avoid further harm or curtailed learning, it is essential that Boards, Committees and professionals involved in the review process are clear about the purpose of the participation of family and significant others. This should appear in the policies/procedures/guidelines as general statements and in the Terms of Reference and texts of reviews as the specific agreement for the particular review. It should include the forms participation can take and the options open to the family.


The policies, procedures and practices reviewed seldom provided explicit inclusion and exclusion criteria. There was evidence of uneven practice, with resources and value based judgements informing the decisions about involvement. We found no evidence to support specific exclusion criteria – in practice all possible participants (parents, children, extended family members, perpetrators of crimes) had provided useful information for the review processes.


A useful and appropriate framework for inclusion is “families and significant others” and the criterion should be any one who was important to that particular family system, the key individuals in the life of the child and their family. Decisions about which family members and significant others should be included must be made on a case by case basis (based on assessment of feasibility and vulnerability). Good practice (in terms of supporting maximum learning) would seem to be an open inclusion criteria without any pre determined exclusions.

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How, Where and When?

The research indicates that the type and nature of family participation hinges on the scoping stage of the review. Current practice in establishing the Terms of Reference for reviews has been most often, to use the guidance contained in Working Together; it is therefore general and minimal. Good practice would seem to require statements that are more substantial and detailed about family participation should be included in the Terms of Reference for each review.

Family involvement in setting the Terms of Reference:

Whilst the specific details of the terms of reference for each review are developed case by case, general guidance for setting the terms of reference should include opportunities for the family to contribute to this early stage, and for the nature and type of their participation to be mapped out very early on in the review process.

It is essential that comprehensive and sensitive planning takes place very early on in the process to determine who should be approached. The participation of family and significant others is not a single event; family involvement may well involve considerable time and effort. A good rapport between the different professionals engaged in leading the review will greatly facilitate this and may help address some of the barriers to participation.

Drawing on the study we recommend four phases in engagement with the family and significant others:

Phase 1: Informing the family and significant others

Great sensitivity is required for this first approach as the evidence suggests it is key in determining subsequent engagement (consideration needs to be given to the most appropriate form of contact). The purpose of this stage is simply to effect introductions and to outline the process, including the points at which family involvement can be negotiated. The study has revealed the confusion experienced by families at this time; care is therefore needed in mapping the review against other, concurrent, processes. There is broad agreement that if this information is conveyed in a letter, it should be hand-delivered by someone who has an established rapport with the family; the involvement of advocates, supporters and translators / interpreters should also be considered at this stage and the family made aware of local support and advice agencies.

Phase 2: The Initial Meeting

This family meeting should describe in detail the process and make clear the roles of those involved. At this stage we suggest that the Terms of Reference should only have the status of draft Terms of Reference. The evidence suggests that it is good practice to give the family the opportunity to make some input into working up the Terms of Reference, within the overall purpose of the review (to arrive at learning). At this stage consideration can also be given to who else should be involved and invited to participate. Families will need clear guidance on publication, the arrangements for hearing about the outcomes and any restrictions in access to the final report.

The family should be encouraged to think about and prepare for their subsequent meetings. They should also be encouraged to think about the questions they want to pose and the support they may require. Just as professionals are expected and required to carry out considerable preparation, so families should be encouraged to undertake some preparation and the short guide at the end of this section may help families and professional arrive at some working arrangements.

Phase 3: The Substantive Interviews/Conversations

The notion of “a conversation with a purpose” has value and whilst this will vary on a case by case basis opening up new ways of families talking with reviewers will facilitate extended learning and information sharing. It cannot be assumed that family involvement will occur through one substantive interview. Multiple meetings and other forms of communication may be necessary. The timing of these conversations will vary on a case by case basis.

There are various practical matters to consider, and the study identifies the importance of these being addressed appropriately. The choice of venue is a highly sensitive matter and the family should exercise choice of venue (where possible). Notes of the meetings with family and significant others must be taken and it is good practice to submit the notes back to the interviewee to confirm accuracy. In some circumstances questions or areas for discussion may have to be submitted to the CPS, Police, and Family Solicitors in advance. All material gathered through the review process is discloseable in any legal action. The timing of such participation may be very sensitive; and the interviewees must be advised of their legal rights, they may need to be seen in the presence of their lawyer.

Families need to be clear that their contribution will be used in the analysis to a greater or lesser degree; but not everything they say will appear in the final report.

Phase 4: Feedback and Follow-Up

The evidence from the study indicates that it is good practice to always offer the family the opportunity to receive and be taken through the Executive Summary prior to publication. There are risks that this may coincide with the end of a trial or inquest and the family may be struggling to cope with multiple events. Careful practice is needed to ensure families are able to digest the contents of the summary, and that they understand how to ask questions at a later stage (if helpful). Crucially, it is important to avoid family members seeing the Executive Summary (albeit anonymised) in the media or on the LSCB website for the first time.

Some practice challenges are posed in conveying the outcomes of the review to factions within a family. Some information will be known to some but not others. Some information may be contentious for the family whose members have some responsibility for the abusive incident and different for those family members who do not have any responsibility. There is a risk that the process of feedback in itself may fuel acrimony. This requires anticipation and preparation, feedback must occur as part of an ongoing process of engagement; and by having this working relationship reviewers should be able to navigate through competing family demands.

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Family participation should not necessarily end with the delivery of the Executive Summary. From the early stages of the review family members should be guided through the proposed arrangements for feedback and any specific ongoing arrangements agreed. Our study provides detailed evidence about the importance and value of ensuring families are aware of change processes, and well supported feedback arrangements will facilitate family involvement. Some form of evaluation of the families’ experience of participation is also useful, and can directly inform future practices.

Prior to the presentation of the Executive Summary there may have been a significant time delay whilst other, related procedures and processes are completed. In these circumstances it is good practice to establish ongoing contact with the family and significant others. This can avoid situations where family and others have contributed considerable amounts of personal and intimate detail (with all the allied emotional outlay) and then hear nothing for months (as indeed so often professionals are also left uninformed for long periods).

Four phases of participation:

Phase One: initial contact and mapping of the review (purpose, remit, and relationship to other processes), identification of any specific support needs of family including use of interpreters and advocates.

Phase Two: negotiation (where possible) of Terms of Reference, agree type and process of involvement, mapping of family members to be involved, facilitation of family preparation including setting out how family information will be used.

Phase Three: substantive gathering of information, including family descriptions of experiences, agreement about ongoing contact and feedback arrangements.

Phase Four: feedback, fulfilling commitments concerned with reporting actions and change, family evaluation of process.

Although for this section of the report, for ease of description, distinctions between four stages have been drawn, in reality the process of family participation (as opposed to an event) needs to be fluid and flexible.

6.2.3 Skills

The family members who have contributed to this research offered clear guidance as to the skills and practices valued:

• Excellent inter-personal skills, including building a rapport and careful communication• Careful mapping of the family and their relevance to the Review• Skilled use of interpreters and translators to ensure families could fully participate• Practices that demonstrated care and recognised the realities of families’ lives• Access to the learning and the proposed plans for change beyond the Executive Summary.

The research with professionals has enabled this analysis of skills to be further extended, and key practices identified.

Valued practices include:

Emotional intelligence, compassion and empathy as highly emotive and complex issues are being shared and analysed

Clarity in communication; being able to clearly articulate the purpose and the process in ways that are meaningful to family members

Active listening and observation The ability to ask probing questions and analyse and structure the resulting information Managing “the burden of intense pain” and engaging with the emotion

Non-judgemental attitudes

Sensitivity, respect and ensuring full preparation takes place before family contact.

This analysis of skills and knowledge raises questions for localities. For example, how are review leads trained and assessed? Families had not had the opportunity to feedback on the quality of the reviewer and such feedback might be invaluable for developing skills and practices in this area. Building in a process of evaluation of the review that is family focused may enable important leaning to be captured.

6.2.4 The ways in which family voices can be heard

In the current environment of a range of interactive communications, the research offered an insight into ways that professionals had developed innovative approaches to hear family members. These included:

• Direct and live contact, i.e. conversations, Skype, telephone.• Direct but not live, i.e. letters, emails, texts, posting on a web page, a diary.• Non-direct, i.e. using advocates to represent family views.

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• Communication with the Panel as a group, i.e. conference call, attendance at a Panel meeting; the use of online technology.• Focus Group; a family conference approach; perhaps led by a navigator to explain, prepare, support and give feedback to the family and significant others.

6.2.5 Support Services/Therapeutic Services

Whilst the concepts of catharsis and closure have been raised by families and by professionals, the review process in itself cannot fully satisfy family members in this regard. Those leading the review should give careful consideration to identifying the need for therapeutic services, and are able to signpost families to these services. This also requires that professionals working with the family are clear about roles and responsibilities and are able to guide families appropriately.

The Role of a Navigator

The range and quantity of concurrent processes suggests that the role of a ‘navigator’ who would be appointed/allocated to the family to help guide them through the various processes and to assist them making good and informed decisions may be a very helpful development. The research with families indicates that family members would welcome this approach.

6.2.6 Public Access

This is a topic which emerged during all our interviews and discussions, although it had not been part of the original interview schedules. It is a topic which generated very strong views and feelings. The decision by the English Coalition Government to introduce full publication raises important ethical dilemmas between (on the one hand) the public good and the public’s right to hold State organisations to account, set against (on the other hand) private rights and privacy. No easy resolution was identified, but rehearsing with families their rights in relation to content and access from the outset was an important means of easing some of the tension.

Public Access

In introducing family participation attention needs to be given to the extent to which families can influence decisions about publication and can register any disagreements with the recommendations (or indeed the decision to hold a review). Protocols about these issues must be carefully explained to families at the start of the process to avoid later, damaging experiences.

6.2.7 Family Guide

We conclude by offering a brief information sheet for family members. This draws on the contributions made by families to the research and provides some suggestions for families who are dealing with the formal case review processes. Family members participating in this research have had the opportunity to read and review this guide.

INFORMATION FOR FAMILIES WHO BECOME INVOLVED IN A CASE REVIEW:

The following ideas come from research undertaken with families who have taken part in a case review. Each situation is different and some of the ideas may be helpful, but some may not. Use the suggestions that seem helpful for you and your family.

• The review is about learning lessons for future professional services. This is the focus and you need to be careful you don’t expect the review to help you in ways that it isn’t set up to do; ask if you are unsure about what the review can help you with.

• The reviewers may not be able to use all the information that you share with them. Plan with the reviewers how they will use your information and ask about who will have access to your information.

• Try to understand what the review does and where it fits in with other professional actions. Ask the professional who talks to you about the review to help you with this and to explain to you what the review does that is different from the other services and actions being taken. It’s often useful if they write this down for you then you can go back and read it at a later stage if events become confusing.

• Talk to the professionals leading the review about why they want you to get involved, and how they will communicate with you about the review as the work progresses. Find out about the different roles people have in the review and who you should ask for help with the review if needed.

• Think about whether you would like a supporter to help you. You should talk to the professional leading the review about who you could approach for help, if you are not sure who you would like to assist you. Families sometimes ask other family members to help them, or they might ask another professional to act as a supporter, or find an organisation that can help them.

• Ask about access to the final reports – find out exactly what you can and cannot see – remember there are limits to what you can be shown because of private information about other people. Have a clear set of arrangements with the lead reviewer about arrangements for hearing about the outcomes of the review. For some families it’s important that this also includes arrangements for dealing with any press interest.

• If you want to know about any changes that come from the review talk to the lead reviewer about how you can hear about these, and who can keep you in touch with progress after the review.

• There are organisations that help families who are involved with care and protection services and case reviews, for example you can contact Family Rights Group for more information www.frg.org.uk, the Victoria Climbé Foundation www.vcf.org.uk and Advocacy After Fatal Domestic Abuse (AAFDA) www.aafda.org.uk.

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A study of family involvement in case reviews Messages for ......(2012) A Study of Family...

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