New Learning from Serious Case Reviews: A two year report for 2009-2011

Funder: Department for Education

Dates: April 2009 - March 2011

Research Team: Professor Marian Brandon, Sue Bailey, Dr Pippa Belderson, (UEA)

Dr Peter Sidebotham, Dr Carol Hawley, Catherine Ellis, Matthew Megson, (University of Warwick)

This is the fourth consecutive two yearly national analysis of serious case reviews (April 2009 - March 2011) undertaken by this research team. The report includes five inter-linking studies which are all informed by the same approach to the exploration of interacting risks which seeks to understand inter-agency working within the dynamic context of the developing child's world.  

Study 1:  There are around 85 maltreatment related child deaths each year.  This estimate comes from setting serious case review data in context with a range of other national data on violent and maltreatment-related deaths in 2009-10.

Study 2:  Statistical analysis on all 184 cases notified as serious case reviews for the period 2009-11 brings our longitudinal database of serious case reviews up to more than 800 cases since April 2003. This allows comparisons with earlier data and commentary on trends over time. Neglect is an underlying feature in 60 per cent of reviews – a much higher prevalence than previously known.  

Study 3:  Thematic analysis of the 21 cases of children aged 5-10 (a hitherto under-examined group) revealed few distinct features and significant diversity.  Yet many children of this age are affected by parental separation and children could be killed or suffer serious harm in the context of acrimonious separations, conflict around contact and domestic violence including on-going threats towards mothers and sometimes children.

Study 4:    An examination of how practitioners' knowledge of child development has an impact on the case and on outcomes for children through an in-depth analysis of six purposively selected reviews. Themes include the significance of bruising on pre-mobile babies and curiosity about the emotional development of children.  For disabled children there was a tendency to see the disability more clearly than the child resulting in a lower standard of parenting for a disabled child.

Study 5:   A study of recommendations revealed an average of 47 recommendations per review. The largely successful endeavour to make recommendations specific, achievable and measurable has resulted in a further proliferation of tasks to be followed through.  

Impact: Three of the 5 separate studies were published ahead of the final report in time to inform the Munro Review of Child Protection. The report as a whole has informed the new edition of Working Together 2013.



Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., and Megson, M (2012) New Learning from Serious Case Reviews: A two year report for 2009-2011, Department for Education, DFE-RR226

Click here to view the full report.