Domestic Homicide Reviews : Is there any learning from Serious Case Reviews Pt II?


The Department for Education has published the latest in its series of biennial reviews of the Serious Case Review (SCR) Process. I have examined the research looking at reviews notified April – March 2009 in a previous blog.

This most recent research looks at notifications of SCRs 2009-2010 cases which pre-date the statutory guidance contained in Chapter 8 of Working Together to Safeguard Children. The research is nevertheless strongly founded in the context of that guidance.

A word on the research methods – a framework for Overview Report recommendations?

The researchers have conducted a thematic analysis of recommendations in 33 SCR notified in 2009/10. They have constructed a framework of analysis of recommendations represented in the following diagram: 

“Reviews vary in their breadth and complexity but, in all cases, where possible lessons should be acted upon quickly without necessarily waiting for the SCR to be completed.”

The multi-agency statutory guidance for the conduct of domestic homicide reviews provides a template for an overview report in Appendix 4. The above structure would provide a comprehensive framework for any recommendations.

Research Findings – Pitfalls to Avoid?

  • The average number of recommendations in 20 cases which were examined in depth was 47 (range 10 – 94)
  • Recommendations which featured most revolved around training, managing the case and interagency working few recommendations considered improved supervision and support as a means to promote professional judgment and reflective practice

Most recommendations were based on learning from the single case and did not consider a wider research evidence base

  • Recommendations that were made were relevant to the case and matched the themes of the review
  • Action plans tended not to address complex issues of professional judgment but were based on SMART (Specific, Measurable, Achievable, Relevant, Timely) principles
  • Societal issues such as deprivation or maltreatment rarely featured  in recommendations or action plans
  • There has been a proliferation of recommendations, actions and tasks there may be other ways of learning from SCRs which may be more difficult to track and measure

“Carrying through these, often repetitive, recommendations consumes considerable time, effort and resources – but there appears to be growing evidence that the type of recommendations which are the easiest to translate into actions and implement may not be the ones which are most likely to foster safer, reflective practice. Having a fully staffed, well supported workforce where regular and challenging supervision is an expectation, is not a simple recommendation to write or follow through.

A number of studies, like this analysis of recommendations, have found that action plans which are easy to implement tend to be ones that address the more superficial aspects of procedures and concrete tasks.”

Statutory Guidance

The statutory guidance for SCRs has a template for Individual Management Reviews which contains a much more detailed framework for the analysis of involvement than the multi-agency statutory guidance for the conduct of domestic homicide reviews.

2 thoughts on “Domestic Homicide Reviews : Is there any learning from Serious Case Reviews Pt II?

  1. Really interesting bit of work, thanks. I wonder if the proposal for a new professional body for policing could be the vehicle for moving beyond case by case analysis, to a more ongoing review and improvement process, that is robust enough to pick up the difficult issues.

    • Hi Jamie, thanks for sharing your thoughts on this. I think the element of self learning is important so I wouldn’t endorse a totally independent investigation. However, I could see no reason why a body couldn’t take the place of the independent Chair/ report writer or indeed provide a pool of people to draw from. I think this would also lend itself to costs savings too, a not insignigicant issue in these times! What I’m not sure about is whether the policing body might lead to “police bashing” for what of a better expression, ie a view that the police alone are somehow responsible for any failings and also concerns about “self policing”. There are often many agencies involved in management of these cases which end in tragedy and for me the actions/inactions of those agencies are important as is the question of what happens in the overlap or the gaps between agencies. Maybe these are concerns that the PR machine could overcome? Certainly the policing body would have the skills needed both to investigate individual cases and to hold a wider view.

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