Education & Family

Child death inquiries will be overhauled, say ministers

Baby P, Victoria Climbie, Kyra Ishaq, Daniel Pelka, Ayeeshia Jane Smith Image copyright ITV/PA/W Mids police/BPM/Family handout
Image caption Serious case reviews were held after the deaths of Baby P, Victoria Climbie, Kyra Ishaq, Daniel Pelka and Ayeeshia Jane Smith

The system of inquiries into child deaths in England where neglect or abuse is suspected will be overhauled, the government has announced.

Serious case reviews will be scrapped and replaced with a new structure of national and local reviews.

The move follows a government-commissioned review of local safeguarding children boards which urged "fundamental change".

Serious case reviews are "too often inadequate", ministers believe.

Cases such as those of Baby P, Victoria Climbie, Khyra Ishaq, Daniel Pelka and Ayeeshia Jane Smith all resulted in such inquiries but there have been suggestions that they have failed to change the system to protect other vulnerable children.

'Fit for purpose'

The report into the role and functions of local safeguarding children boards argues that the system needs "significant reform" to meet new threats and risks to children and "become consistently effective overall".

Author Alan Wood, a former president of the Association of Directors of Children's Services, says that while there are many examples of good practice there is "too much acceptance of less than good performance".

"There needs to be a much higher degree of confidence that the strategic multi-agency arrangements we make to protect children are fit-for-purpose, consistently reliable and able to ensure children are being protected effectively," says the report.

Mr Wood recommends:

  • a new statutory framework to promote stronger local co-operation on child protection between police, health services and local government
  • local agencies to be encouraged to design their own child protection structures best suited to local needs
  • serious case reviews to be replaced by a national body to consider lessons when the system fails.

The new body should consider what factors characterise a good inquiry, draw up guidance and recruit a skilled cohort of accredited case reviewers, he argues.

Image copyright Family handout
Image caption Ayeeshia Jane Smith died from a tear to the heart in May 2014 - her mother was jailed for 24 years

The report notes that more than 80% of child deaths are medical or health related, while 4% relate to child protection issues.


The government response, says the report "has set us on the right road to enable local areas to build on the best of what already exists and to think innovatively about how wider improvements can be made".

It accepts that current arrangements are "inflexible and too often ineffective" and promises "a stronger but more flexible statutory framework" for local child protection and safeguarding.

The new system replacing serious case reviews will improve the consistency, the speed and quality of local and national reviews and ensure the lessons learned inform social work practice, says the government.

A Department for Education spokesman welcomed Mr Wood's "insightful report".

"That is why our new Children and Social Work Bill already sets out provisions to set up a new panel to manage a centralised process, which will help to resolve long-term issues of quality, timeliness and dissemination of national lessons, and why we will put in place measures to improve multi-agency working, as recommended."

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