At the end of July, the Department for Education published a report commissioned from Kingston University called “A study to investigate barriers to learning from serious case reviews“.  The report pulls no punches and ought to prompt a fundamental rethink about the purpose and utility of these expensive and often protracted pieces of work.

When things go wrong, it is always a good idea to reflect on what led to mistakes with the ultimate intention of preventing them happening again. One of the biggest criticisms of Serious Case Reviews has been that somehow, the same mistakes seem to happen time and again regardless of the length, expense or apparent quality of the review. Put simply, it seems that we seem to be really good at identifying mistakes and less good at learning from them. It is in this particular area that the new report bears the most utility.

The report highlights “how the length, time and content of SCR publications create an ethos of ‘blame,’ avoidance, apathy, defensiveness and increased workload. This is exacerbated by media coverage. The number and dispersal of SCRs nationally means it is difficult  to give them all local attention, and what gets attention is then skewed and determined by national media selectivity and coverage. “; and goes on to point out that

  • The numbers of recommendations that generate new policies and procedures is overwhelming.
  • SCR reports are not accessible in terms of length and common language to make them meaningful and manageable to all users across different sectors, professions and agencies. Key themes and learning are not adequately identified nationally.
  • The SCR process is itself costly in terms of finance and capacity and may not generate the most useable or interpretable learning for local practice.
  • There is concern about publication in full and how this relates to transparency and confidentiality.

The report covers a good deal more and taken as a whole provides (in my view) the single most useful instrument to facilitate change in what has in many examples become a tired and ritualistic process that at best is far less than optimal and at worst, is thoroughly unhelpful.

It is to be hoped that having commissioned this report the DfE will now use it as the catalyst for the development of a new approach to learning from mistakes and one that ensures that lessons are embedded into practice.

Watch this space!

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