The Voice of The Child: Learning Lessons From Serious Case Reviews

The voice of the child: learning lessons
from serious case reviews

A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to
30 September 2010
This report provides an analysis of 67 serious case reviews that Ofsted evaluated
between 1 April and 30 September 2010. The main focus of the report is on the
importance of listening to the voice of the child. Previous Ofsted reports have
analysed serious case reviews and identified this as a recurrent theme which is
considered in greater detail here.
Published: April 2011

Reference no: 100224
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Contents
Executive summary 4
Key findings 4
Background 4
Learning lessons: the voice of the child 5
Seeing and hearing the child 6
Practice implications: 8
Listening to adults who speak on behalf of the child 8
Being alert to parents and carers who prevent access to the child 11
Focusing on the child rather than the needs of parents and carers 13
Interpreting what children say in order to protect them 15
Annex A: Working together to safeguard children 19
Annex B: The children and the incidents 20
The children 20
Annex C: The 67 Serious Case Reviews 24
Executive summary
This report covers the evaluations carried out between April and the end of
September 2010 of 67 serious case reviews. The main focus of this report is on the
importance of listening to the voice of the child. Previous Ofsted reports have
analysed serious case reviews and identified this as a recurrent theme. This report
provides an opportunity to explore this key issue in more depth and draw out
detailed practice implications.
Key findings
There are five main messages with regard to the voice of the child. In too many
cases:
 the child was not seen frequently enough by the professionals involved, or was
not asked about their views and feelings
 agencies did not listen to adults who tried to speak on behalf of the child and
who had important information to contribute
 parents and carers prevented professionals from seeing and listening to the child
 practitioners focused too much on the needs of the parents, especially on
vulnerable parents, and overlooked the implications for the child
 agencies did not interpret their findings well enough to protect the child.
Background
Ofsted has been responsible for evaluating serious case reviews since 1 April 2007.
The review of child protection by Professor Eileen Munro is considering possible
changes to the serious case review process. Professor Munro has recommended in
her interim report1 that in due course Ofsted should cease to have responsibility for
the evaluation of serious case reviews. The reviews and the evaluations under
consideration here were conducted in accordance with the current statutory guidance
set out in Chapter 8 of Working together to safeguard children: a guide to inter-
agency working to safeguard and promote the welfare of children.2 Annex A, sets out
the circumstances in which a Local Safeguarding Children Board must consider
conducting a serious case review.
Ofsted has previously published four reports on the lessons to be learnt from serious
case reviews. These reports have covered serious case reviews evaluated by Ofsted
between April 2007 and the end of March 2010.
1
The Munro review of child protection: Interim report, the child’s journey, Department for Education,
2011; www.education.gov.uk/munroreview/.
2
Working together to safeguard children: a guide to inter-agency working to safeguard and promote
the welfare of children, DCSF, 2010;
www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010.
4 The voice of the child: learning lessons from serious case reviews
April 2011, No. 100224
Many of the lessons identified in previous reports have been similar. Rather than
repeat the same messages this report provides a thematic analysis drawn from
evaluations completed during the six months from April to the end of September
2010. This report does not focus on the data behind the reviews, or the Ofsted
evaluations of those reviews, but instead provides an in-depth focus on one theme:
the voice of the child, drawing out practice implications for practitioners and for Local
Safeguarding Children Boards.
Learning lessons: the voice of the child

1. This section focuses on the lessons to be learnt by the key safeguarding
agencies from the 67 serious case reviews which were evaluated by Ofsted
between the beginning of April and the end of September 2010, focusing
specifically on the voice of the child.
2. Of these serious case reviews, 65 concerned a total of 93 children. Twelve of

these 65 reviews were about two or more children, including one case involving
a family of seven children and another which concerned a family of six children.
The first of these two cases spanned two generations. Annex B contains the
data relating to the profiles of the children and their families.
3. The principal focus of the other two serious case reviews was on adult
perpetrators rather than on individual children and their families. The reviews
examined the lessons to be learnt about local agencies’ failure to identify abuse
carried out over an extended period of time. These cases are therefore not
included in this thematic report.
4. Six main messages were set out in the most recent Ofsted report, Learning
lessons from serious case reviews 2009–2010.3 Those messages continue to
recur in the reviews covered by this report. They are about the importance of:
 focusing on good practice

 ensuring that the necessary action takes place
 using all sources of information
 carrying out assessments effectively
 implementing effective multi-agency working
 valuing challenge, supervision and scrutiny.
5. Above all, previous Ofsted reports have identified that too often the focus on
the child was lost; adequate steps were not taken to establish the wishes and
feelings of children and young people; and their voice was not heard
sufficiently. This report provides an opportunity to consider in more detail the
practice implications of these themes for practitioners and for Local
Safeguarding Children Boards.
3
Learning lessons from serious case reviews 2009–2010 (100087), Ofsted, 2010;
www.ofsted.gov.uk/publications/100087.
The voice of the child: learning lessons from serious case reviews
5
April 2011, No. 100224
6. Five key themes about the voice of the child have been identified in the
serious case reviews evaluated between April and the end of September 2010.
In too many cases:
 the child was not seen frequently enough by the professionals involved, or
was not asked about their views and feelings
 agencies did not listen to adults who tried to speak on behalf of the child
and who had important information to contribute
 parents and carers prevented professionals from seeing and listening to the
child
 practitioners focused too much on the needs of the parents, especially
vulnerable parents, and overlooked the implications for the child
 agencies did not interpret their findings well enough to protect the child.
7. These five messages about the importance of listening to the voice of the
child are illustrated in the following pages by examples from the 65 cases
involving children. All the material is drawn from published executive
summaries.
Seeing and hearing the child

8. Serious case reviews highlighted the importance of seeing, observing and
hearing the child. However, in some of the reviews they found that the child
was not seen by the professionals involved or was not seen frequently enough.
In other cases, even where the child was seen, they were not asked about their
views and feelings. Serious case reviews also stressed the importance of
ensuring that practitioners’ observations are clearly recorded and the
consequences which can arise when this does not happen.
9. Many of the cases concerned babies and young children who were too
young to express their feelings in words. One serious case review highlighted
good practice in addressing this issue. Attention had been given to reporting
and recording observations of the parents’ interaction with their baby during his
time in the neo-natal unit. Staff were aware of risk factors and early indicators
in the context of safeguarding. In this case, staff observations did not make
them concerned as both parents seemed appropriately involved in caring for
their baby.
10. However, other serious case reviews concluded that alternative approaches
were not always used. For example, while the subject of one review was a baby
who had died following non-accidental injuries, there was concern that no-one
had spoken to the three-year-old half-sibling when she was in distress. The
serious case review found that: ‘No consideration was given to the impact of
the adult’s capabilities on the children or on what the older children had to say.
The impact was that assessments about the children’s needs missed a vital
component.’
April 2011, No. 100224
11. Although some reviews underlined the importance of observing the child’s
behaviour with the parent, others also stressed the need for children to meet
on their own with practitioners. In a case involving a teenager who committed
suicide, one of the lessons learnt was that the young man was rarely seen on
his own and the majority of professionals did not seek his views. The review
concluded: ‘Children must be seen alone by professional staff working with
them, and their wishes and feelings recorded.’
12. Another finding was the importance of the location chosen for seeing the
child. In some cases, this meant that the children needed to be seen in places
that were familiar to them. This was illustrated by the case of a boy with autism
who died as a result of smoke inhalation from a house fire. He had been left on
his own in the building, trapped in a room with no internal door handle.
Although assessments had taken place, the review found:
‘Most of the assessments undertaken directly with the child were made at
the respite carer’s home, the respite unit or the school. He was rarely seen
at home. Some professionals involved in his care never saw the child.’
13. By contrast, one serious case review highlighted the difficulties that children
faced in revealing their concerns when they were seen in their home
environment. In this family, the children had suffered from neglect, physical
and sexual abuse over many years. It was only when the children were
removed from the home environment that they were able to speak about the
abuse which they had suffered. A lesson from the review was that priority
needed to be given to providing a safe and trusting environment, away from
the carers, for the children to speak about their concerns.
14. In one case, one of the children had revealed small pieces of information
about his life at home while at school. However, the key professional who
received this information, saw it as a priority that the parents be informed. As
the review stated:
‘The emphasis on sharing information with parents must not override the
rights of a child to privacy and the provision of a safe way to discuss their
concerns with professionals.’
15. Serious case reviews involving disabled children commented on the

importance of practitioners using appropriate means of communication. One
case concerned a disabled girl who was found dead in her bedroom, which had
been locked overnight by her parents. A conclusion of the serious case review
was that:
‘Disabled children have the right to receive a comprehensive child-focused

assessment of their needs in which their views and expectations are
central, with the full participation of all agencies involved so that the
needs of the disabled child are not allowed to mask safeguarding and child
protection concerns.’
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April 2011, No. 100224
16. In ‘seeing and hearing the child’ there are a range of adults that have both
the opportunity and the information to help the child be ‘seen’ and ‘heard’.
These include grandparents, neighbours and members of the public. For very
young children, this may be by simply sharing their perceptions and
observations. The failure of agencies to take account of information that is held
by others is explored in more detail in the next section: ‘listening to adults who
speak on behalf of the child’.
Practice implications:
Practitioners should:
 use direct observation of babies and young children by a range of
people and make sense of these observations in relation to risk factors
 see children and young people in places that meet their needs – for
example, in places that are familiar to them
 see children and young people away from their carers
 ensure that the assessment of the needs of disabled children identifies
and includes needs relating to protection.
Listening to adults who speak on behalf of the child

17. A recurring message in these serious case reviews is the important role of
adults who are in a position to speak on behalf of the child. The adults include
parents, grandparents, neighbours and members of the public. This section
considers examples where the adults put forward important information, but
their views were not taken seriously enough.
18. In many cases there were risks from an over reliance on what parents said
and this is addressed in the next section of this report. However, there were
also important messages when professionals overlooked the views of parents.
One such case involved a family in which the mother and father were
separated. One of the children, living with the mother, was sexually abused by
the mother’s partner. The father passed information many times to Children’s
Services and to the police that the mother’s partner was a registered sex
offender and had unrestricted access to the children. Although the agencies
took some steps to monitor or restrict access, the serious case review
concluded that the child’s father ‘was not properly listened to and it is essential
that safeguarding professionals who come into contact with the public never
forget how it feels for people when they are trying to penetrate what to them is
an apparently impervious wall’.
19. A common theme in these serious case reviews, which has also been
highlighted by Local Safeguarding Children Boards in previous serious case
April 2011, No. 100224
reviews, has been the tendency for agencies to overlook the role of fathers,
male partners and other men living within the families. In many instances, the
concern related to the risk that the men posed for the children, but in other
cases the men had information that agencies would have found helpful in
understanding the child’s situation, especially when the child concerned was too
young to speak for itself.
20. In one example, a baby aged two months suffered head injuries when in the
sole care of his mother. She had been drunk at the time and had a history of
alcohol misuse, the impact of which had been underestimated by the
professionals involved. Despite the fact that information was gathered from
other relatives in this case, this did not include the father, even though he was
living with the mother. A finding from the review was that the father had been
marginalised.
21. In four of the cases covered by this report, lessons were learnt about the
failure of agencies to recognise the role of grandparents in representing the
voice of the child. One or more of the grandparents in each of these cases
reported their concerns about the care of their grandchildren but this did not
lead to effective action to prevent the serious incident. The Local Safeguarding
Children Boards found that the views of the grandparents should have been
taken more seriously and should have contributed to a more complete
understanding of the problems in the families.
22. One of these reviews concerned a family of seven children over two
generations. The grandmother had contacted social care on a number of
occasions, alleging sexual and physical abuse of the children by the children’s
stepfather. She had also written to the Director of Social Services. 4 This did not
trigger child protection procedures. It was over a decade later that disclosures
were made by the eldest children in the family, revealing the long-standing
abuse that had taken place.
23. Eight reviews also commented on the role of neighbours and members of
the public, concluding that there was a need to facilitate channels for the public
to speak up on behalf of children when they had serious concerns. One Local
Safeguarding Children Board said:
‘This review highlights the fact that often the agencies have to rely on
members of the public as their “eyes and ears”. Neighbours, family and
friends are often in a better position to see or become aware of possible
child protection issues. The potential value of the general public in the
child protection task needs to be better exploited. Some thought and
attention needs to be devoted to development of strategies to unlock the
potential.’
4
The letter to the Director of Social Services pre-dated the establishment of Directors of Childrens’
Services.
9
April 2011, No. 100224
24. In some instances, where a parent committed a serious act against a child,
the reviews commented that no concerns had been reported by members of the
public, even though people had witnessed bizarre behaviour by the parent. By
contrast, in other cases concerns reported by members of the public had not
been followed up adequately by the safeguarding agencies. One review
concluded that it was a salutary lesson that the best practice came from
neighbours and family friends who had raised alarms about the family. This
Local Safeguarding Children Board recognised the barriers that neighbours may
face in terms of disbelief from professionals and sometimes intimidation from
the families of the children whom they are trying to protect.
25. However, one case illustrates the very valuable, and fortuitous, role of a
member of the public. A two-year-old boy was taken by his mother to a
supermarket. A member of staff in the supermarket noticed that the child was
severely emaciated and that the mother was buying food suitable for a child
aged only three to six months. Recognising the uniform of the boy’s sibling, the
staff member passed on the concerns to the school. Staff at the school
identified the family and conveyed the information to children’s social care. The
boy was found to be suffering from severe malnutrition and developmental
delay. These concerns had not previously been noticed by the agencies
involved with the family.
26. Agencies which have regular access to the family home may also be in a
good position to represent the child’s perspective. For example, in one review a
housing organisation recognised its potential role identifying situations or
observing indicators that suggest children might be at risk. As a result of the
review, the organisation introduced a reporting system to be used by housing
repair staff if they wanted to refer a concern.
April 2011, No. 100224
 routinely involve fathers and other male figures in the family in
assessing risk and in gathering all the information needed to make an
assessment.
Local Safeguarding Children Boards should:

 consider how they can better engage the general public in
safeguarding children.
Being alert to parents and carers who prevent access to the

child
27. The third message from the reviews is the importance of practitioners being
alert to parents and carers who prevent access to their children. When this
happens, agencies are unable to hear the children’s views or to make
observations about the interactions of parents and carers with them. One
review described, for example, how the children had been threatened into
silence by the adults in their lives so that they were unable to reveal the
catalogue of serious abuse that they had been experiencing.
28. In the most clear-cut examples, when practitioners tried to make contact
with the families, the behaviour of parents and carers was aggressive and
threatening towards the practitioners. This is illustrated in one case which
found:
‘The fact that father was regarded as very volatile and potentially and
actually quite violent is also likely to have constrained the effectiveness of
practice in this case. On many occasions, professionals were not allowed
into the home and/or prevented from seeing mother and the children.
There were several periods of up to two weeks when professionals could
not see or make contact with mother or see the children.’
29. Serious case reviews found that practitioners failed to make the connection
between the difficulties that they themselves experienced in these situations
and the likelihood that the children in the family were also undergoing stressful
and abusive behaviour. This is summarised in the multi-agency
recommendation in one of the reviews:
‘When professionals from any agency have concerns about their own
personal safety, they must always consider the implications for children
from exposure to the same risk factors.’
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April 2011, No. 100224
30. There were other ways in which the actions of parents and carers resulted in
professionals not seeing the children. These included examples in which the
mother minimised the impact of domestic abuse or provided false assurance to
professionals about the home situation.
31. This is illustrated by a case in which a teenager was shot by his mother. A
referral had previously been made to children’s social care by a community
psychiatric nurse. However, this had not resulted in an assessment because the
mother had provided assurance that there was no need for social care to be
involved. In this example, the Local Safeguarding Children Board found that the
views of the parent or carer had been too easily accepted, rather than
professionals seeing and talking to the children directly.
32. Another review concerned a young disabled child who suffered a serious
incident of domestic abuse. This case also illustrated the need for professionals
to challenge parents. The Children with Disabilities Team saw their role as
family support workers to the exclusion of identification of child protection risks.
The serious case review found that the need to respect the privacy of parents
had led to an inadequate focus on the child. Too much attention had been paid
to forming a trusting relationship with the adults at the expense of considering
whether good enough care was also being provided for the child.
33. Other ways in which parents and carers prevented agencies from seeing
children were through missed appointments for the children or by withdrawing
them from school. The issue of children being educated at home was a factor in
three of the 65 serious case reviews.
34. One of these serious case reviews was carried out after a teenage girl
disclosed to the police that she and her elder sister had been sexually abused
by their father. There had been concern over several years about the care
provided for the children in the family. The two sisters and two other siblings
had been withdrawn from school by their parents to be educated at home. The
serious case review concluded that, with the benefit of hindsight, it was clear
that the children had been withdrawn from school to avoid the scrutiny of the
authorities. A related lesson was that when the children were withdrawn from
school, children’s social care should have been alerted because of the previous
concerns about the family.
35. In another case that involved a child’s death due to malnutrition, the child
and two siblings had been removed from school to be educated at home. The
review concluded that:
‘At no point were any of these children given the right to choose the
location, the nature of provision, or any right to consultation to express
their views as part of this process. There was no independent access to
friends, family or professional agencies; they were isolated’
and
April 2011, No. 100224
‘There are no mechanisms to ensure that a satisfactory education
continues to be received, or that young people’s welfare is appropriately
safeguarded, except with the express cooperation and participation of
parents and carers.’
36. The serious case review found that the unintended outcome of home
education legislation in these instances had been to restrict professionals’
access to the children. This worked to the advantage of those parents who
wanted to conceal abuse.
 consider the implications of risk to children where they have concerns
for their own personal safety
 ensure that respect for family privacy is not at the expense of
safeguarding children.
Local Safeguarding Children Boards should:

 consider how children who are home educated can receive the same
safeguards as their peers.
Focusing on the child rather than the needs of parents and

carers
37. A lesson from some of the serious case reviews was that practitioners had
not listened sufficiently to the child or had not paid enough attention to their
needs. This was because they had focused too much on the parents, especially
when the parents were themselves vulnerable. As a consequence, agencies
overlooked the implications for the child.
38. This was well summarised by one Local Safeguarding Children Board which
stated:
‘The serious case review identifies the need to maintain a focus on the
child throughout any work being undertaken and suggests that there can
be a tendency to lose balance and focus more on the needs of the
parents, particularly the main caregiver.’
39. An example of this concern was highlighted in a case involving a baby boy
who suffered non-accidental injuries. The mother had a history of mental health
problems and there were reported issues of domestic violence in the family.
The serious case review found that psychiatric professionals had shown
sensitivity to the mother’s needs. However, they had discounted the
13
April 2011, No. 100224
significance of the domestic abuse and how its interaction with the mother’s
mental health might increase risks for the baby.
40. There was a similar message from a serious case review that involved
another young baby who suffered skull fractures. The family was known to
agencies due to the mother’s misuse of alcohol. In its conclusion, the Local
Safeguarding Children Board found that staff in adult-focused health services
should have established the mother’s childcare responsibilities and should have
assessed the impact of her drinking and depression on the child. The serious
case review was concerned that, except on one occasion, some hospital staff
had not made a link between the admission of a very drunk mother of a baby
and how that affected her ability to care for her child.
41. This lack of attention to the impact of parental needs on the child is even
more apparent when the child takes on a caring role for the parent. One case
concerned a teenage girl who lived with her mother despite the fact that her
seven older siblings had been removed from the mother’s care. Concerns about
the home situation over a long period included: inappropriate male adults in the
home; allegations of sexual abuse; aggression by the mother to professionals
and to the children; threats by the mother to take her own and the children’s
lives; and two apparent suicide attempts by the teenage girl. The review was
carried out following disclosure by the girl that she had been sexually abused
by a male lodging with the family.
42. In this case, many important lessons were learnt. One of these was that the
impact of the mother’s mental health on her daughter, and especially the caring
role for the mother that the daughter had assumed, was never fully assessed. A
finding of the review was that there should be formal consideration whether to
undertake a young carer’s assessment when there are concerns about parental
mental health.
43. A recurring theme within these serious case reviews was the response of
agencies, particularly the police, to the implications of domestic abuse on
children within the family. One serious case review found that the police had
dealt appropriately with the domestic abuse against the mother but had not
responded to allegations of assault by the mother’s partner on the children in
the family. The Local Safeguarding Children Board concluded that the police
should have initiated child protection investigations and found that they had
failed to include details of these allegations when they notified children’s social
care about their contact with the family.
44. Even when the reported violence was between the parents and did not
physically harm the children, there was a failure in several cases to consider
whether the children were also at risk. As one review concluded:
‘If the case had been managed with more rigorous attention to the needs
of the children, rather than the main focus being on the domestic abuse
by the father and on the mother’s mental health problems, it is likely that
April 2011, No. 100224
better arrangements would have been in place to ensure that the children
were kept safe.’
45. One case took this concern a stage further. In this instance, the risk
assessment did consider the effect of the incidents on the children who had
been present but it had not taken account of incidents that occurred while the
mother was pregnant. The review found that the unborn child was at great risk
but he had not been considered by the agencies involved in the same way as a
victim of the incident or as a child that had been present. The concerns were
magnified further by the finding that the baby’s grandmother had reported her
concerns to the police and to health professionals but these had not been
followed up sufficiently.
46. In respect of the unborn child, the agencies involved have a key role in
representing the child’s interests as a proxy for the voice of the child, including
any safeguarding implications from their assessment of the family. This was
evident in a case which involved the death of a baby on the day that he was
born. The mother had concealed the pregnancy. It became apparent after the
baby’s death that she had concealed the pregnancies, to varying degrees, of
her two other children who survived. The Local Safeguarding Children Board
found that agencies, in their previous involvement with the mother both before
and after the children were born, had had a focus on her rather than on her
children. Agencies had not challenged the mother about her lack of
engagement with the services they had provided for her.
 recognise the specific needs of children and young people who have a
caring responsibility for their parents
 always consider the implications of any domestic abuse for unborn
children
 be alert to how acute awareness of the needs of parents can mask
children’s needs.
Interpreting what children say in order to protect them

47. The fifth message about the importance of the voice of the child is that,
even when professionals gathered evidence from the child’s perspective, there
were too many cases in which they did not really listen to what they were told
or did not interpret the evidence in a way that would safeguard the child. There
was a difference between hearing the voice of the child and the actions that
followed.
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April 2011, No. 100224
48. At the most basic level, children and young people felt that they had
disclosed their concerns but these had not been followed up. For example,
when family members were interviewed as part of one serious case review,
they identified an occasion when one daughter had spoken to a teacher about
her father’s physical abuse of her and her siblings. They were surprised that no
action had been taken and said that this had inhibited the child from reporting
her father’s later sexual abuse.
49. In another case, the serious case review found that at least twice the
children in the family had identified safeguarding issues in front of professionals
but neither of these occasions had led to a core assessment. The review
referred to a quotation from one of the children that he had been hit by his
father, which was contained in the referral that led to an initial assessment. A
few years later, when the mother was arrested for being drunk in charge of a
child, there was no child protection investigation despite one of the children
being reported as saying: ‘She’s always doing this.’
50. Of particular concern were cases where allegations were made by different
family members without this leading to action to protect the children. In the
case about a family of seven children spanning two generations, referred to
earlier, the serious case review found that one of the subjects of the review had
attempted to alert professionals on at least three occasions. Allegations had
also been made by the children’s grandmother, a family friend and the
stepmother but no effective action had been taken to protect the children. The
failure of agencies was well articulated by the oldest girl in the family through
her contribution to the serious case review. She identified the following missed
opportunities for professionals to intervene: not seeing her alone; insufficient
enquiry by school staff about visible signs of abuse; lack of curiosity by GPs
despite her successive pregnancies; and lack of action by neighbours due to
fear or uncertainty.
51. Even when practitioners did listen to children and others who represented
the voice of the child, lessons were learnt about the difficulties and sometimes
the shortcomings in interpreting what was seen and heard. In individual cases
agencies overlooked or misinterpreted:
 signs of grooming by a sex offender

 the significance of domestic violence and parental aggression
 the difference between discipline, chastisement and physical abuse
 the significance of poor school attendance
 delinquent misbehaviour when it resulted from the offender being the victim
of abuse by an adult
 the impact on the child from fulfilling the role of carer for a parent
 the impact of the agencies’ low expectations about parenting because of
local cultural norms.
April 2011, No. 100224
52. In the lessons learnt from one review there was a recognition that
professionals needed to improve their understanding of the available
information in terms of assessment and the management of risks. The review
found that professionals needed to ask the question, ‘What are they trying to
tell us?’ when analysing children’s behaviour.
53. One case that illustrates this concerned a teenage girl who had been the
subject of images on the internet in which she was seriously sexually abused.
She and her brother had both been ill-treated and neglected by their mother
and sexually abused by their uncle. The family had been well known to
agencies in three local authorities where they had lived. When agencies
reviewed their involvement with the children it became clear that there was
sufficient information for the abuse to have been recognised by practitioners
long before the internet images were discovered. One of the main lessons for
agencies from this review was the importance of practitioners being able to
interpret the indicators of sexual abuse, including those potentially related to
grooming and coercion.
54. A common theme from the reviews is that, when interpreting evidence about
the child’s perspective, professionals should not automatically accept what they
are told by parents or carers at face value. One review concluded that there is
‘a need for respectful uncertainty’ when interpreting parental contributions.
However, other reviews found that, in some circumstances, there is also a need
to override the wishes of children and young people. Although the main focus
of this report is about the importance of listening to the voice of the child, a
salutary message from two of the reviews is that there are times when
professionals should not accept everything that they are told or agree to
everything requested by children and young people.
55. One of these two cases concerned an articulate teenage girl whose
behaviour at times was very challenging for her mother and professionals. Her
death was believed to have been self-inflicted. The review found that, although
there were many positive aspects of the services provided for the girl by a
range of professionals, agencies had decided not to hold meetings without her
involvement. The serious case review concluded that this was an omission and
that agencies had gone too far in their efforts to ensure that the girl’s wishes
and feelings were met. This case underlines the importance of professionals
using their judgement, even where this means overriding the views of the
young person.
56. In the second case, there had been concerns about abuse in the family over
many years. Despite this, the young person had expressed a wish to stay at
home, continuing to do so even after care proceedings commenced.
Nevertheless, the review recognised that the girl had also demonstrated her
unhappiness through her behaviour and concluded: ‘What children say is only
one dimension of understanding what they actually mean.’ There was also
support for this conclusion in the young person’s own contribution to the
17
April 2011, No. 100224
serious case review, in which she recognised that action to safeguard her
should have been taken earlier.
 ensure that actions take account of children and young people’s views
 recognise behaviour as a means of communication
 understand and respond to behavioural indicators of abuse
 sensitively balance children’s and young people’s views with
safeguarding their welfare.
April 2011, No. 100224
Annex A: Working together to safeguard children
Working together to safeguard children requires that where a child dies and abuse or
neglect is known or suspected, the Local Safeguarding Children Board must conduct
a serious case review.5 It must also consider conducting a serious case review
where:
 a child sustains a potentially life-threatening injury or serious and

permanent impairment of physical and/or mental health and development
through abuse or neglect
 a child has been seriously harmed as a result of being subjected to sexual
abuse
 a child’s parent has been murdered and a homicide review is being initiated
 a child has been seriously harmed following a violent assault perpetrated by
another child or adult
and the case gives rise to concerns about the way in which local professionals and
services worked together to safeguard and promote the welfare of children.
The purpose of a serious case review is:
 to establish whether there are any lessons to be learnt from the case about
the way in which local professionals and organisations work individually and
together to safeguard and promote the welfare of children
 to identify clearly what these lessons are both within and between agencies,
how and within what timescales they will be acted upon and what is
expected to change as a result
 to improve intra- and inter-agency working and better safeguard and
promote the welfare of children.
5
Working together to safeguard children: a guide to inter-agency working to safeguard and promote
the welfare of children, DCSF, 2010;
www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010.
19
April 2011, No. 100224
Annex B: The children and the incidents
Of the 67 serious case reviews reported on here, Ofsted’s evaluation judged one to
be outstanding, 33 were good, 31 were adequate and two were inadequate. By
comparison, in last year’s report6 covering 147 reviews in the full year from April
2009 to March 2010, 62 were judged to be good, 62 were adequate and 23 were
inadequate. Fewer serious case reviews have been judged inadequate in the period
covered by this report and, for the first time since Ofsted took over responsibility for
the evaluations, a review has been judged as outstanding.
The children
Of the 93 children, 39 children died. The other 54 were involved in serious incidents
which resulted in a decision by the Local Safeguarding Children Board to carry out a
serious case review.
The age profile of the children was similar to that found in previous Ofsted reports,
as shown in Table 1. A majority of the children involved were five years old or
younger at the time of the incident.
Table 1: Ages of children who were the subject of a serious case review evaluated
by Ofsted between 1 April and 30 September 2010
Number of serious case

Age range
reviews
Under 1 year 31
1–5 years 18
6–10 years 13
11–15 years 23
Over 16 years 8
Total 93
6
Learning lessons from serious case reviews 2009–2010 (100087), Ofsted, 2010;
www.ofsted.gov.uk/publications/100087.
April 2011, No. 100224
Table 2 compares the age range of those who died and those who were subject to
other serious incidents. There is little difference in the two profiles, except that a
higher proportion of the children under five years died as a result of the incidents.
Table 2: Number of child deaths and other serious incidents by age group
between 1 April and 30 September 2010
Died Other serious Total

incidents
Under 1 year 18 13 31
1–5 years 9 9 18
6–10 years 4 9 13
11–15 years 5 18 23
Over 16 years 3 5 8
Total 39 54 93
Forty-seven girls and 46 boys were the subject of the serious case reviews, which is
a similar distribution to the findings in previous years.
Ethnicity data were recorded for all except two children. The largest grouping was
White British (73 out of 93 children). No children were recorded as Asian; nine were
recorded as Black African, Black Caribbean or Black Other; and eight were recorded
as Mixed. In one case the ethnic category used (Afghan national) was not a standard
census category, and in two cases the child’s ethnicity was not stated as only the
mother’s ethnicity was known.7
There were nine disabled children, ranging from those with a learning disability to
those with severe and complex conditions. Fifteen children had special educational
needs and five of them had a special need statement.
Of the 93 children, 70 were known to children’s social care at the time of the
incident. There were other children who had been known to the services previously
but were not known at the time of the incident.
Twenty-seven children were receiving services as children in need at the time of the
incident; nine of these children died. Of the 27 children in need, 12 were the subject
of child protection plans.8 A further 17 children had previously been the subject of a
child protection plan at some stage in their lives.
Four children were looked after by the local authority; two of the children died. Of
these two children, one was an unaccompanied asylum-seeking young person who
committed suicide while in semi-independent accommodation; the other was a
disabled child who died of natural causes while living with foster carers.
7
Census 2001 ethnic categories are used.
8
The children recorded as being children in need but not having a child protection plan included those
who were children in need because of their disability, those who were looked after by the local
authority and those who had previously been the subject of a child protection plan and continued to
be judged to be children in need by children’s social care services.
21
April 2011, No. 100224
The cause of death is shown in Table 3.
Table 3: Cause of death of the 39 children who died
Cause of death Number of deaths

Homicide
Murder by parent or carer 11
Other9 11
Other external cause

Suicide 5
Death from drowning 1
Accidents and adverse events

Concealed birth 1
Overlay by parent or carer 2
Unknown cause 5
Natural causes 3
TOTAL 39
The deaths recorded as ‘unknown cause’ included cases where no definite reason
could be determined by the coroner or no conclusion had been reached at the time
that the serious case review was completed. The category covers instances of
‘sudden unidentified death in infancy’ and other cases in which young babies died,
where overlay by the mother or the effects of parental use of alcohol or drugs may
have been factors.
Apart from the 39 children who died, the serious case reviews concerned 54 other
children. The most common characteristics of the incidents were physical abuse,
sexual abuse or long-term neglect. In some instances there was a combination of
factors.
9
Includes deaths arising from malnourishment, neglect, physical abuse, shaken baby syndrome or
arson.
April 2011, No. 100224
The above data are based on 65 of the 67 serious case reviews. The remaining two
cases were about the perpetrators of abuse, rather than the victims. One case
concerned a foster carer who was arrested for sexual offences against children
whom he and his wife had been fostering over a 10-year period. The other case was
about two perpetrators of physical and sexual abuse at a residential special school.
This followed a disclosure by one of the students, which resulted in a major and
complex investigation.
23
April 2011, No. 100224
Annex C: The 67 Serious Case Reviews
Local Safeguarding Children Serious case review Date of
Board evaluation evaluation letter
Barking and Dagenham Good 12/08/2010
Birmingham Adequate 07/04/2010
Birmingham Adequate 14/06/2010
Blackburn with Darwen Good 19/05/2010
Blackpool Adequate 17/08/2010
Bradford Good 26/07/2010
Buckinghamshire Adequate 06/04/2010
Buckinghamshire Adequate 24/08/2010
Bury Adequate 09/07/2010
Cambridgeshire Adequate 23/06/2010
Central Bedfordshire Good 11/06/2010
Derby City Adequate 07/05/2010
East Riding Good 26/07/2010
Enfield Adequate 24/05/2010
Essex Adequate 12/08/2010
Essex Good 13/09/2010
Gloucestershire Adequate 17/06/2010
Hackney Good 09/08/2010
Hackney Good 12/08/2010
Herefordshire Good 16/08/2010
Hertfordshire Adequate 14/04/2010
Hertfordshire Adequate 19/04/2010
Hounslow Good 06/07/2010
Hounslow Inadequate 26/07/2010
Islington Good 19/08/2010
Kent Good 03/06/2010
Kent Good 06/07/2010
Kingston upon Thames Adequate 16/09/2010
Kirklees Good 26/05/2010
April 2011, No. 100224
Knowsley Adequate 11/08/2010
Lancashire Adequate 31/08/2010
Leeds Good 13/05/2010
Leeds Good 12/07/2010
Leicestershire and Rutland Good 23/09/2010
Lewisham Adequate 01/04/2010
Liverpool Good 12/07/2010
Manchester Outstanding 06/04/2010
Manchester Good 19/04/2010
Manchester Good 13/08/2010
Newham Good 13/05/2010
North Lincolnshire Adequate 27/08/2010
Nottinghamshire Good 10/05/2010
Nottinghamshire Good 17/06/2010
Rochdale Good 06/04/2010
Rochdale Adequate 11/08/2010
Rochdale Adequate 27/08/2010
Rotherham Adequate 17/06/2010
Sefton Good 05/07/2010
South Gloucestershire Good 11/06/2010
Southampton Good 13/05/2010
Southend Good 09/07/2010
Southwark Adequate 20/09/2010
St Helens Good 10/05/2010
St Helens Good 23/09/2010
Swindon Adequate 03/08/2010
Tameside Good 08/04/2010
Tameside Adequate 24/06/2010
Wakefield Good 12/08/2010
West Sussex Good 27/07/2010
Wirral Adequate 27/07/2010
Wolverhampton Adequate 14/06/2010
York Inadequate 24/08/2010
25
April 2011, No. 100224

The Voice of The Child: Learning Lessons From Serious Case Reviews

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The voice of the child: learning lessons

from serious case reviews

Published: April 2011

T: 0300 123 1231

Learning lessons: the voice of the child

2. Of these serious case reviews, 65 concerned a total of 93 children. Twelve of

 focusing on good practice

Seeing and hearing the child

15. Serious case reviews involving disabled children commented on the

‘Disabled children have the right to receive a comprehensive child-focused

Listening to adults who speak on behalf of the child

Local Safeguarding Children Boards should:

Being alert to parents and carers who prevent access to the

Local Safeguarding Children Boards should:

Focusing on the child rather than the needs of parents and

Interpreting what children say in order to protect them

 signs of grooming by a sex offender

 a child sustains a potentially life-threatening injury or serious and

The purpose of a serious case review is:

Number of serious case

Died Other serious Total

Table 3: Cause of death of the 39 children who died

Cause of death Number of deaths

Other external cause

Accidents and adverse events

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