Preventing child death from maltreatment
Submitting InstitutionUniversity of East Anglia
Unit of AssessmentSocial Work and Social Policy
Summary Impact TypePolitical
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Studies In Human Society: Social Work
Summary of the impact
Since 2006 the University of East Anglia (UEA) has led a series of
Government commissioned studies of all Serious Case Reviews of child death
and serious injury in England. This work has provided the largest national
database of analyses of child deaths and serious injury where abuse or
neglect are known or suspected.
Since 2008, the findings have informed public understanding, practitioner
thinking, multi-agency child protection practice, policy and law - in the
UK, and internationally. Both key child protection policy and practice
reviews commissioned by the UK Government 2008-13, the Laming report
(2009) and the Munro Review of Child Protection (2011), drew on
In England, there is a requirement to set up multi-agency Serious Case
Reviews following death or serious injury of children where maltreatment
is a possible factor. National biennial analyses of these reviews have
been commissioned by Government Departments since 1998 to improve child
protection policy and practice. In undertaking these reviews the aim has
been to identify what lessons can be learned from these cases and to find
ways to minimise the circumstances that can lead to a child being harmed.
Research studies at UEA
The focus of this case study are the four (continuous) Government funded
biennial studies of all Serious Case Reviews in England 2003-11.The
studies were conducted 1. 2006-8, 2. 2007-9, 3.
2009-10, 4. 2010-12.
This research has all been conducted by teams led by Marian Brandon,
using an approach which tries to understand more about both the
circumstances which might trigger the death or serious injury of a child
and the factors which influence the behaviour of the practitioners working
with the children and their families. The mixed method, ecological and
transactional approach requires a dynamic understanding and assessment of
children and their families and of human development across the life span.
This work has provided the largest national database of analyses of child
deaths and serious injury where abuse or neglect are known or suspected.
To date the research has produced a systematic analysis of more than 808
cases in total (from 2003-11) with 505 (62.5%) deaths and 303 (37.5%)
This research programme drew on previous UEA child protection studies led
by Thoburn and Brandon since the 1990s, funded by the Department of Health
and the NSPCC. Howe's expertise on child development and abuse has
informed the theoretical approach. Thoburn and Howe are now Professors
Emeritus. Since 2007, Sidebotham, a consultant community paediatrician and
Associate Professor at Warwick University, who specialises in child death,
has also contributed to the research.
Marian Brandon is Professor of Social Work and Director of the Centre for
Research on Children and Families (CRCF).
Key findings from the CRCF biennial analyses of Serious Case Reviews
include an enhanced understanding of the following:
• The vulnerabilities in children, stresses in parents and interactions
between children, parents and workers that can lead to maltreatment
resulting in death or serious injury.
• The ways in which workers become overwhelmed and the impact this has on
their practice and decision making (particularly where there is complex
neglect), making the case for improved staff support, more robust
supervision and a fully staffed workforce.
• The similarities of the profile of the cases where children die with
other complex cases, making prediction very difficult, and requiring
practitioners to be highly attuned to changes in family functioning.
• The particular vulnerability of infants, with a high proportion of
infant cases of death and serious injury not being previously known to
children's social care.
• The absence of awareness among professionals and policy makers of the
impact of serious maltreatment on adolescents.
References to the research
All projects were government funded through competitive tender following
peer review. Grants awarded to Marian Brandon from the Department for
Children, Schools and Families/Department for Education (DCSF/DfE) total
£364,347, (2006-2012). An advisory group, comprising policy makers,
academics and stakeholders, provided a rigorous peer review for each study
and each report.
Research reports for Government - also distributed to local
authority safeguarding boards
1. Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R.,
Dodsworth, J. and Black, J. (2008) Analysing child deaths and serious
injury through abuse and neglect: what can we learn? A biennial analysis
of serious case reviews 2003-05. London: Department for
Children, Schools and Families, DCSF-RR023.
2. Brandon, M., Bailey, S., Belderson, P., Gardner, R.,
Sidebotham, P., Dodsworth, J., Warren, C. and Black, J. (2009) Understanding
Serious Case Reviews and their Impact: A biennial analysis of serious
case reviews 2005-07. London: Department for Children, Schools and
3. Brandon, M., Bailey, S., and Belderson, P. (2010) Building
on the learning from Serious Case Reviews: a two year analysis of child
protection database notifications 2007-2009, Department for
Education. Research Report DFE-RR040.
4. Brandon, M, Sidebotham, P, Bailey, S and Belderson, P, Hawley,
C, Ellis, C and Megson, M (2012) New learning from Serious Case
reviews: a two year report for 2009-2011 London: Department for
Peer reviewed journal articles
5. Brandon, M., Belderson, P., Warren, C., Gardner, R., Howe, D.,
Dodsworth, J., and Black, J. (2008) `The preoccupation with thresholds in
cases of child death or serious injury through abuse and neglect, Child
Abuse Review, 17(5) 289-364.
6. Brandon, M. (2009) `Child fatality or serious injury through
maltreatment: Making sense of outcomes', Children and Youth Services
7. Sidebotham, P., Bailey, S., Belderson, P. and Brandon, M.
(2011) Fatal child maltreatment in England, 2005-2009. Child Abuse and
Neglect. 35(4): 299-306.
Details of the impact
Brandon and the series of UEA studies have had a direct and significant
impact on child protection policy and practice since 2008, with a reach
across the UK and internationally. Findings from the two earlier studies (References
1, 2, 5, 6, 7) have continued to influence current policy and
practice alongside the third study (References 3, 7) and the most
recent study (Reference 4). The pathways to impact have
been primarily through the publication and dissemination of the Biennial
Reports (References 1, 2, 3, 4) to all Local Safeguarding Children
Boards by the DCSF/DfE, the incorporation into required procedure and
practice nationally and locally and the role of Brandon in dissemination
and consultation on policy, practice and procedure, nationally and
internationally. Journal articles (References 5, 6, 7) have
broadened the reach, especially internationally. Beneficiaries are at all
policy and practice levels.
Government Policy: findings influenced the 2010 edition and the
2012 consultation edition of Working Together to Safeguard Children
in England. The Brandon et al. (2008, Reference 1)
recommendation for greater numbers of health visitors was taken up in
the 2009 Laming inquiry report, as well as four other references to the
studies. Significant material from the studies was used in practice
guidance for Safeguarding Disabled Children (2009). References
to these studies appeared in the three Munro Review Reports. Brandon was
invited to give oral evidence to the Government Select Committee on the
Munro Review recommendations (October 2011) and to advise civil servants
about changes to Serious Case Review reporting in the Working Together
guidance being drafted (March 2012). Brandon presented at UK `Four
nations' events on the development of child death review work
nationally. • Contribution to social work reform: The NQSW Guide
for Supervisors of Newly Qualified Social Workers (2009) draws heavily
on Brandon et al (2008 Reference 1) The Social Work Task Force
Interim Report (2009) uses UEA Serious Case Review evidence about
supervision. This evidence led to consultation with the General Social
Care Council and Children's Workforce Development Council on
implications for social work education.
Practitioners: National Government distribution of UEA reports
(2008, 2009, 2010, 2012, References 1, 2, 3, 4), reinforced by
two annual rounds of nine regional practice-focused seminars throughout
England in 2008 and 2009. Brandon has given keynote addresses at Local
Safeguarding Children Board (LSCB) conferences in England, Wales,
Scotland and Northern Ireland. `Case Studies' in the reports advise
practitioners on how to link findings to practice. Many LSCBs have UEA's
Serious Case Review reports on their website. UEA has organised national
practice focused conferences in London and through the `Making Research
Count' network. The Metropolitan Police Service (Child Abuse
Investigation Command) introduced a Child Risk Assessment Model using
UEA biennial studies' risk factors in 2011. The Lead Officer's report to
Child Protection Committees in Scotland (2011), commended Brandon et al
for their `excellent research report' on child development knowledge
from Serious Case Reviews to all practitioners this report was initially
published in 2011 and incorporated into the 2012 biennial report
Non-governmental groups: The NSPCC used evidence from the
Serious Case Review studies for its 2010 restructuring into seven
themes. In 2011 their All Babies Count campaign used UEA's
findings in their campaign leaflet illustrating the ways in which
infants are at risk of serious harm. The report on which the campaign
was based, mentioned the `hugely influential' Brandon et al report (Reference
1). The 2013 NSPCC report How Safe are Our Children? uses
the most recent study (Reference 4) substantially as a guide to
its messages about child death and the level of risk children face.
Society: Brandon played a significant role and led national
debate on protecting children from abuse - particularly in the context
of the death of `Baby P', through media interviews e.g. Radio 4, Radio
5, local radio, BBC TV News, News 24, ITV News, Sky News, Guardian,
Telegraph, Daily Mail, New Statesman and professional press, e.g.
Community Care and Nursing Times.
- Brandon and Thoburn were asked to advise the State of Victoria's
Minister for Families and Communities (March 2008).
- Consultancy for New South Wales (NSW) Ombudsman Office about child
death review processes (April 2011) resulted in changed definitions of
neglect in NSW. Presentation about child death through maltreatment to
Melbourne Judiciary (August 2010).
- The keynote address and Masterclass at the 3rd Australasian
Child Death Review Conference in Sydney in 2012, together with previous
consultation, resulted in a significant change in policy- the
involvement of the child's family in the child death review. This change
is being implemented in Victoria (and considered in other states).
- Round Table events at La Trobe and Melbourne Universities in September
2007, 2010, and Melbourne University's Centre for Excellence 2010 and
Sources to corroborate the impact
Links to research /references by numbers in bold.
- 19 February 2008: Letter from Kevin Brennan, Parliamentary Under
Secretary of State, to Chairs of Local Safeguarding Children Boards
emphasising `the importance of acting on the findings' of the report Analysing
child deaths and serious injury through abuse and neglect: what can
we learn? A biennial analysis of serious case reviews 2003-2005
(Brandon et al 2008, Reference 1)
- The Lord Laming (2009) The Protection of Children in England: A
Progress Report, London: TSO (recommendations of the report draw
heavily on Brandon's work, e.g. recommendations 13, 15,16, 20 and 24
on pp.85-88 reflect specific implications for safer practice from,
Brandon et al (2008 Reference 1), also cited pages 24, 38, 57
and 65. These recommendations were taken up by the government and
incorporated into guidance Working Together 2010 (see below).
Laming Report http://dera.ioe.ac.uk/8646/1/12_03_09_children.pdf
- Department of Children, Schools and Families (2009) Safeguarding
Disabled Children Practice Guidance, DCSF-003474-2009DOM-EN (3
citations pages 34, 40, 47 Brandon et al, 2008 Reference 1,
and 2009, Reference 2 )
Facing up to the Task: Interim report of the Social Work Task
Force (2009) drew on Brandon et al's work to emphasise the
inadequacies in, and the importance of, staff care and supervision in
protecting children. This has contributed to the emphasis on social
work expertise in child protection, as also reflected in the Munro
Review. Citation page 17, Brandon et al, 2008, Reference 1)
- Children's Workforce Development Council (2009) NQSW Guide for
Supervisors 2009-10 Leeds: CWDC. 11 separate citations, pages
101,102,103,105,107,115, 120,130,132, 136,139, (Brandon et al, 2008, Reference
- Department of Children, Schools and Families (2010) Working
together to safeguard children: A guide to inter-agency working to
safeguard and promote the welfare of children 4 citations pages
259, 263, 267, 271 (Brandon et al, 2009, Reference 2) https://www.education.gov.uk/publications
The Munro Review of Child Protection
(2011) 4 citations pages.16, 86, 96, 150 Reference 3
(Brandon et al, 2010). https://www.education.gov.uk/publications/eOrderingDownload/Munro-Review.pdf
- Email from Wendy Mayne, Office of the Child Safety Commissioner,
State of Victoria, Australia `Your work on engaging families could not
have come at a better time and will assist us to strengthen practice'.
National Guidance for Child Protection in Scotland: Guidance for
Health Professionals in Scotland (2013) draws on Brandon's
research in several sections and on p.82 refers to 7 separate
publications by Brandon and the research team under `The Unseen Child'
and `High Risk Families', including References 1, 2.
- NSPCC report How Safe are Our Children? (2013) 4 citations
pages 12, 14, 64, 65 (Brandon et al, 2012 Reference 4) and
uses the research to underpin their synthesis of child safety