Ofsted publishes report on lessons to learn from serious case reviews

Ofsted has today published a report which analyses 67 serious case reviews carried out by local safeguarding children boards across the country when a child dies or abuse or neglect is known or suspected.

The inspectors found that in too many cases the children involved were not seen frequently enough by the professionals involved, or were not asked about their views and feelings.

Another finding from the report was that practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child. In one case where this occurred, a young baby suffered skull fractures. The family was known to agencies due to the mother's misuse of alcohol. The review found that staff in adult-focused health services should have established and assessed the impact of the mother's drinking and depression on her childcare responsibilities.

Agencies did not listen when adults who tried to speak on behalf of the child and had important information to contribute. The report highlights where the concerns raised by fathers, grandparents, neighbours and even members of the public could have helped to protect children had they been taken seriously. For example, in four of the cases, grandparents reported their concerns about the care of their grandchildren but this did not lead to effective action to prevent the serious incident.

Christine Gilbert, Her Majesty's Chief Inspector, said: "It is shocking to see that too often children in vulnerable situations are not heard by those who should be looking out for their interests. That is why this report's focus on listening to children is so important. The report shares valuable lessons that can help protect children and prevent such tragic incidents.

"I hope all involved in the protection of children will read the report and take stock of the importance of observing and listening to children, using different approaches to encourage children to speak openly and taking account of those who speak on their behalf."

The report follows a recommendation in February by Professor Eileen Munro in her interim report on child protection that Ofsted should cease to have responsibility for the evaluation of serious case reviews.