Dates: April 2018-March 2020
Research Teams: Prof Marian Brandon, Prof Jonathan Dickens, Dr Penny Sorensen, Dr Pippa Belderson (UEA). Dr Peter Sidebotham, Dr Jo Garstang, Dr Hedy Cleaver, Dr Julie Harris, Dr Russell Wate (Warwick University) with Research in Practice  
Funder: Department for Education

Complexity and challenge provides an underlying theme in this review of SCRs from 1 April 2014- 31 March 2017. As we looked into the reviews of children affected by serious and fatal child maltreatment, we were struck by the complexity of the lives of these children and families, and the challenges – at times overwhelming – faced by the practitioners seeking to support them in such complexity.

This study builds on the ‘pathways to harm, pathways to protection’ model developed for our previous triennial review of SCRs from 2011-14.  The model has helped us to explore the complexity of families’ lives within the central ‘pathways to harm’ component, and the challenges faced by practitioners in statutory and other agencies within the ‘pathways to protection’ component. We have been able to look beyond the complexities and challenges to consider the opportunities for prevention and protection, and the values, systems and processes that might help support this work.



  • The increase in SCRs noted between 2011- 2014 has not continued into 2014-17. The numbers of children who die each year as a direct consequence of maltreatment have held relatively steady at an average of 28 cases a year. By contrast, SCRs for children experiencing non-fatal serious harm have increased from 32 per year across 2009-14 to 54 per year in 2014-17.
  • This plateauing of child death numbers is occurring in the context of year on year increase in child protection activity nationally, with a rise in both section 47 enquiries and child protection plans.
  • We found pressure points at the boundaries into and out of the child protection system, and the need for ongoing support and monitoring of vulnerable children and families. There are cumulative risks of harm when different parental and environmental risk factors are present in combination, in particular, the damaging impact of poverty.
  • Learning from cases of neglect, from adolescent exploitation and from reviews of children in care and on special guardianship orders, a number of lessons for practitioners were highlighted. These build on previous lessons, and include recognition of the lived experience and the story of the child and their family; the importance of building lasting practitioner relationships with children and families; greater rigour in information sharing, assessment and planning at all stages of the process; and opportunities for building effective structures and promoting responsive cultures, even when constrained by limited resources.