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Neglect most common feature in non-fatal Significant Case Reviews in Scotland

Neglect was the most common feature in non-fatal Significant Case Reviews and Initial Case Reviews in Scotland, the Care Inspectorate has stated.

In a report reviewing the findings from review reports submitted to the Care Inspectorate between 1 April 2018 and 31 March 2021, including key findings from analysis of 50 ICRs that did not proceed to a full SCR, 23 SCRs and two thematic learning reviews, the Inspectorate highlighted how neglect can affect children and young people of any age group.

“Neglect was the main feature in non-fatal reviews, affecting 35 children. While the majority of children subject to reviews where neglect featured were under 11 years, a third of the children were aged 12-17 years. Neglect is an issue that can affect children of all ages,” said the report.

A SCR is a multi-agency process for establishing the facts of, and learning lessons from, a situation where a child has died or been significantly harmed. SCRs should be seen in the context of a culture of continuous improvement. An ICR precedes a SCR and is the process through which child protection committees consider relevant information, determine the course of action and recommend whether a SCR or other response is required.

Almost 40% of reviews followed the death of a child or young person (28 of 75 reviews). The most common cause of death was suicide involving eight young people, closely followed by drug-related deaths of seven young people.

Areas identified in the review for learning and development included:

  • Information sharing
  • The role of the person acting as the professional point of contact in universal services or ‘named person’ and lead professional
  • The quality of assessment and analysis of risk.

“These are familiar themes that have been highlighted in our previous SCR overview reports and inspections. These areas continue to be addressed through local CPC improvement plans,” said the report.

Decision making is inconsistent across Scotland about when and why SCRs are carried out, the Inspectorate said adding that they hoped the clarity of the new Learning Review Guidance (2021) will support greater consistency as it provides revised criteria for carrying out learning reviews and places an emphasis on the additional learning that will be gained from a review.

“Across the child protection landscape there is a range of work being undertaken to strengthen and improve child protection practice. This includes the publication of new guidance, establishment of the learning review liaison group and the learning review knowledge hub. We anticipate that they will provide opportunities to better support local and national learning,” the report concluded.


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