Major changes to inquiries into child deaths

Topics covered: Ridouts professional advice

The Government has announced that inquiries into child deaths where instances of neglect or abuse are found will be revised. The change has been prompted following a report which looked into local safeguarding children boards and found them to be woefully inadequate and in need of reform in respect of detail and process.

The main issue relates to the level of rigour and inconsistency of approach in relation to each case that is brought before the board. In the report its author, Alan Wood, former Association of Directors of Children’s Services president, states that there is a culture of accepting below par performance when assessing local safeguarding children’s boards.

The report recommends a number of changes to improve local and national performance in relation to the handling of child deaths including: –

–  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; and

–  serious case reviews to be replaced by a national body to consider lessons to be learned when the system fails.


The proposed new national body could provide a more consistent approach when assessing child deaths and also when looking at ways to prevent these incidents so far as possible in the future.

The Government has recently responded to the report from Alan Wood and has largely agreed to adopt many of the recommendations made in the report. It has agreed to implement the following:

·         introduce a more flexible statutory framework which will set out requirements for local partners- whilst allowing them the freedom to organise themselves in any manner that they see fit to achieve these aims;

·         replace Serious Case Reviews and miscellaneous reviews with a system of national and local reviews to ensure consistency and objectively high levels of quality in completing these reviews;

·         set up an independent national panel responsible for commissioning and publishing national reviews and also investigating those complex cases it deems will provide the best opportunity to learn nationally;

·         transfer national supervision of Child Death Overview Panels from Department for Education to the Department of Health.

These changes are welcomed to bring much needed clarity and consistency of approach across the topic of child deaths where neglect or abuse are involved. Unfortunately no timescale has been set for when these changes will come into place but it would be reasonable to assume that they should be completed in the coming year subject to parliamentary approval.

The other point that requires further thought relates to the movement of power to investigate child deaths away from localised bodies towards a larger national panel. Whilst it is not disputed that the larger national panel will have greater consistency of approach and independence it may fail to have the necessary power to change the way that things are done locally- something that a more localised approach may be better placed to do.

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