Serious Case Reviews – Style & Content – (6 of 9)

The Reports – Style & Content

The three reports themselves were entirely different in size and scope. The first (Carly) was very detailed, properly numbered, logical in its layout and easy to read (in the stylistic sense). The second (Kyle) was similar (it was written by the same person) but would have benefited from a more consistent layout. The third was simply inadequate. If I had produced a report like this when I was working for Coopers & Lybrand I would have had it thrown back to me and been told to do it again. Let's not forget the authors of these reports are getting paid for writing them.

I found it surprising that there was not a standard format, so that one report can be compared to another and that the ground they cover can be seen to be consistent.

The layout of all three reports is different. Report B is 23 pages long, and gives a clear picture of the circumstances that lead to Carly's death. Report D is 13 pages long, is not quite as clear on the circumstances of Kyle's death and contains 3 and half pages of recommendations. Report E (Chloe) is none of these things.

It is only 8 pages long (and that includes the title page) and has slightly more than half a page of recommendations. And of those scant pages only four short paragraphs are about Chloe herself. Four! Seven sentences and one of those was about the Coroner's verdict and another about her family being known to various agencies. One sad life (and even sadder death) disposed of in 142 words.

The whole tone of this report (read to me) as that summary suggests – as cold & dismissive. As 'care less' as the response of the agencies it reports on to the obvious screams of a child in distress and her mother desperately seeking to understand what she could do. This is best demonstrated by quoting two paragraphs;

9.7. "With hindsight, it is possible to speculate that a holistic, child-centred assessment of the family during this period, taking the full history into account, might have led to a clearer understanding of the degree to which the mother was struggling to meet Child E's needs and a more intensive and better coordinated preventative support plan. However, the lengthy history and complex nature of the factors in Child's (E) life mean that this may not have resulted in a different outcome."

9.9. "There are many young people who suffer a difficult childhood and adolescence, but who have sufficient resilience or have developed coping mechanisms which allow them to make a successful transition into adulthood."

In other words, more might possibly have been done, but it probably wouldn't have made any difference. And anyway other young people have got over it. So that's all right then!

My response to this report was one of anger. All the findings are vague, superficial and lack detail. If you were searching for clues as to why the various agencies failed to prevent Chloe's death, you won't find them here, other than they didn't seem to talk to one another, but we are assured they, "...did their best...".

Clearly their best wasn't good enough.