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The Role of Child Death Inquiries

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Keywords: public inquiry child death, social work inquiries

Recently the benefits of child death inquiries and serious case reviews have come under particular scrutiny (Corby, Doig and Roberts, 1998). This assignment will use evidenced based information and practice to find other approaches or how to improve the form of the inquiry so its benefits outweigh its limitations.

The United Nations estimate that every week two children in the United Kingdom die from abuse or neglect (UNICEF, 2003). The United Nations Convention, article 3 on the rights of the child places a duty on countries to protect children from abuse or neglect, the best interests of the child must be the primary concern when making decisions which may affect them, article 6 focuses on the importance of safeguarding their right to life (United Nations Convention on the Rights of the Child, 1992).

There are two types of child death inquiries; serious case reviews and public inquiries. A serious case review takes place when a child dies and abuse or neglect is suspected. They also take place in other circumstances where serious situations have occurred for example where a child has suffered from serious sexual abuse. The purpose of child death inquiries according to Working Together, 2010 is for agencies and individuals to learn where problems have arisen and to learn from these to improve their practice. The lessons learnt should be given to all individuals who work in this area to ensure they safeguard children in the correct way. When agencies already know where certain problems lie they should improve upon them before the serious case review is finished. A public inquiry for example The Colwell Report (1974), The Climbé inquiry (2003) is a inquiry ordered by the government to review events, in this case child deaths. To conclude where practice could be improved upon, recommendations can be given and lessons can be learnt.

Under regulation 5 of the local safeguarding children's board requires that the local safeguarding children board undertakes reviews of serious cases. Serious case reviews must establish lessons to be learnt, identify which lessons are within agencies and which between and how long they have to act upon the changes to be undertaken. The reviews must also improve upon inter and intra agency working to promote and safeguard the wellbeing of children (chapter 8, Working Together, 2010). Laming (2009) states that serious case reviews are an important tool for learning lessons. Currently there is debate regarding the approach used in serious case reviews some believe that there are different approaches to take to learn from poor social work practice. Effective safeguarding practice is an approach considered, to learn from what is already proven to work.

The obvious aim of child death inquiries is to try and avoid future tragedies. There is a repetitive circle within child protection. Families collide with professionals and most of the outcomes involve protection. The tensions involved between families and professionals involve competition of rights. The Human Rights Act, 1998 article 8 stipulates the family's right to a private family life and to be able to conduct their lives according to their culture and understanding. The opposite to this argument is to ensure all children are protected. When should professionals become involved? Parton (1991) describes the dilemma of how can the state establish the rights of the child and still promote the family to be an independent body in which to raise their children how they see fit and not intervene in all families and consequently reduce its autonomy.

Depending on the theoretical viewpoint the professionals and current Government takes would impose when the state should intervene. A laissez-faires government would have little intervention. State paternalism is a perspective which favours more involvement of state intervention to protect children from abuse. This theory regards the child's welfare as more important than family autonomy. This perspective was reflected in the Children Act, 1989 as it introduced the expression likely for the child to be in significant harm. If there is a likelihood of significant harm there are possibilities of child protection orders being produced, and in other extensions of state power.

Tensions between the duties that social workers have to safeguard children, the family's right to a private family life, the rights of the child, working in partnership with the parents and understanding when the state should intervene cause problems within social work practice. Knowing when to intervene has always been a problem for social workers within this area. Malcolm Hill (1990) found that published child abuse inquiry reports identified working with parents as a common problem. He found that papers noted access difficulties, in a number of cases parents didn't cooperate when the social worker needed to see the child at risk. Hill (1990) concluded that papers found social workers were too ready to believe parents. Hill (1990) concluded that the Colwell report (1974) found that social workers should focus on parents demonstrating their parenting skills and not to assume all was well because the parents said so.

Social workers also need to look at the care the child is receiving holistically not focus on single areas of the family where they are showing positive steps, for example social workers may be satisfied as the family are participating in counselling but they need to still look at their parenting at home whilst this continues. Thus depending on the theoretical viewpoint the social worker takes decides when they should intervene. This assignment will adopt a state paternalism perspective, this perspective although draws conclusions that the child is likely to suffer significant harm which may affect the family relationships and autonomy it's better to intervene now then wait until abuse or neglect has taken place and then safeguarding the child. This perspective takes a view that children have a high priority in society, they have rights to high standards of care and using this approach ensures that they are protected at all costs by the force of the law (Fox Harding, 1997).

Child death inquiries are seen as an important tool used to improve local practice and implementing wider community health approaches to improve upon infant mortality rates. Bunting and Reid (2005) found that there numerous benefits to serious case reviews taking place. These included; more effective multi agency working, improved communication between agencies, they found that death certificates had become more informative they also found that from participating in serious case reviews practitioners had more knowledge surrounding child death and the causes of them ensuring a further focus on preventative measures of child death rather than focusing on child abuse.

Corby et al (1998) have found that there is a growing concern on the impact of child inquiries on professionals especially social workers. They found that whilst inquiries were taking place social workers face continual criticism. The Maria Colwell case made social work practice public and put it under great scrutiny. Professionals within this case became points of focus of criticism, their work was scrutinised in incorrect contexts focusing on training of social workers affecting their morale significantly (Corby et al, 1998).

The impact of child death inquiries on social workers and other professionals in this area can be psychological and emotional. Corby et al (1998) argues both sides of the case that child death inquiries can highlight poor practice and the need for the public to know why children already known to social services and other departments can still go on to be abused and killed. However the emotional and psychological effects on social workers can be so detrimental because of the scrutiny they are under, their work will be affected, and affecting further work they do.

Corby et al (1998) investigated child abuse cases and inquiries and how useful they are and what changes have been made by using child death and abuse inquiries as an approach. Of the seventy inquiries they investigated between 1945 and 1997 they all produced similar recommendations in areas of improving inter agency co-ordination, training of professionals, improving child protection systems and using more experienced staff. Corby used this information to highlight that changes made between 1945 and 1997 have not been substantial as inquiries continue to make the same recommendations.

Child death inquires do have their place in the public eye specifically when practice goes wrong, nevertheless they have a number of limitations. Child death inquiries affect personal confidence of the social workers and other professionals when they become embroiled within the investigation. Due to the nature of the child death inquiries the public only see the negatives of social workers, social workers fear the association of such inquiries. Practice will not change when inquiries focus solely on the structure of children and families department. If social workers feel like the target when involved in inquiries their work will be affected therefore affecting the work they do further on for example other children may be more at risk because social workers have no confidence in the work they are practicing.

To use child death inquiries as a vehicle for policy development may not be the most effective approach to take. Child death inquiries are very expensive. If a more effective approach was to be taken and social workers and other professionals were able to learn more from this different process it would be more beneficial to take this approach than to carry on using money and concluding the same issues. Parton (2004) has found that the same issues have been identified on numerous times without any obvious changes in social work practice. Devaney, Lazenbatt and Bunting (2010) found that child death inquiries can still be effective but more emphasis needs to be on recommendations, implementing and acting upon them. Devaney et al (2010) also argue that policy makers need more understanding of the difficult situations in which children are at more risk from abuse or neglect. Devaney et al (2010) argue that this can help the policy makers express what social workers can do and make a distinction between that and what should be done.

Child death inquiries make assumptions that something has gone wrong and that the inquiry can find out what and give recommendations to learn from the mistakes. It assumes that practice will change because of the recommendations given and many inquiries don't focus on acting upon the recommendations, if they did then future inquiries wouldn't produce the same recommendations. Inquiries assume that the method they use is sophisticated. However, research into inquiries and literature has shown that other approaches could be more effective and less intrusive in practice and less strain can be put on professionals. Inquiries assume that multi agency working will be more effective, though if tensions between professionals are problematic then these will be difficult to resolve. Inquiries cannot assume that these tensions can be worked at by the professionals they need a superior management style to overlook the different professionals to be able to work effectively together.

As well as the implications for social workers individually and for policy makers regarding the process of child death inquiries, organisational structures will be also be impacted upon when changing child welfare policy. Due to changes within organisations, for example changes in roles of professionals involved in child death inquiries the foundations of interprofessional multi agency work are not secure, concluded because inquiries focus excessively on the role of social workers rather than the antecedents of child death or abuse. With regards to the case of Maria Colwell (1974) the Secretary of State Barbara Castle concluded that social workers alone cannot solve the underlying problems. All professionals in this field of child welfare need to understand their role but if child welfare policy continues to change constantly the role cannot be undertaken as professionals have poor ideas of what their role is and how they should practice. All professionals need to work effectively together and have an understanding of delivering comprehensive services to diverse communities so no children are lost in the system or ignored. The importance of effective interprofessional multi agency work is such that until there is a balance of role and practice then the safeguarding of future children may be affected.

Contemporary social work values may be affected, social workers have their own values personally and from learning from experience. Social workers must focus on human rights and social justice as their motivation for social work. Some critiques may argue that depending on the theoretical framework for example state paternalism some social workers may not be able to justify their motivation to impose this framework in their practice by not letting the family have a right to private family life (Human Rights, article 8) and be too quick to intervene. To ensure anti discriminatory practice social workers must understand different cultures have different behaviours when it comes to parenting. The social worker may think it is not appropriate, the family however may believe differently. This can lead to the social worker to not act at all. The social worker must ensure anti discriminatory practice, they need to see things from the perspective of the culture the family employs. Though still maintaining the values and knowledge they have regarding child abuse and when they should intervene. They must keep each case individual and make judgements based on evidence, not on their assumptions.

To evaluate how useful child death inquiries are as a vehicle for policy development evidence needs to be considered whilst investigating journal papers to gain an understanding of where bias may occur. Using a wide range of sources gives a broader idea of what has been proven to work in social work practice (Roberts and Yeager, 2006). Research evidence is more valued than other sources, those papers that are repeatable and use a large amount of participants are more likely to have less prejudice in concluding how useful child death inquiries are as a vehicle for policy development. Higgs and Jones (2000) propose that evidence is knowledge derived from various sources, which has been tested and found credible.

Having read all the information the weight of evidence suggests that changes need to be made to the approach of child death inquiries. The limitations and implications to practice are too substantial to ignore. Professionals and public haven't seen any major changes because of the recommendations give by the inquiries. Corby et al (1998) found that of seventy public inquiries between 1945 and 1997 the main focus of recommendations was on improvements on inter agency co-ordination and improving the training of staff. The gap between the time of the death of the child and receiving the results of the inquiry is detrimental to social workers. Corby et al (1998) also argue that the cost of inquiries and the negative impact on social workers affecting their future practice may create more risk to other children they are safeguarding because they don't have the confidence to practice anymore. The most effective approach to take would be one that focuses with less scrutiny on the social workers so their confidence is not affected and acts upon the recommendations it has made. Policy can develop by using a different vehicle instead of child death inquiries. At the minute the impact of changing child welfare policy on social workers and organisational structure is considerable. An improved approach to child death inquiries can be more effective in changing policy than the constant changes that are currently happening because of the results from child death inquiries.


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