A critical analysis of the Haringey Serious Case Review in the case of Baby Peter Conolly 2009.

A critical analysis of the Haringey Serious Case Review in the case of Baby Peter Conolly 2009.


The requirement for a Serious Case Review (SCR) in the event of a child fatality was by and large a product of a recent policy development by the state (DCFS, 2010). The expectation of these reports is to determine the cause of the death of the child with reference to any possible failures on the part of social welfare organizations or professionals in order to prevent such failure in the future and to take the necessary action for professional negligence where appropriate. In a recent report by the department of education, a criticism was raised that often these inquiries focus on a professional error rather than the cause of such error (Munro, 2011). Following the death of Peter Conolly, the social welfare professionals involved were given a warning for professional error in judgment, however this was reviewed and the social workers were dismissed. Following on from this, the social workers appealed this decision at the Employment Appeal Tribunal, however this too was dismissed. The tribunal ruled that although the social workers’ arguments of an overburdened workload were valid, there was a professional error made on the part of the social workers and their dismissal was accordingly valid. The research therefore will seek to examine any detrimental effect that this may have on the profession of social work nationally as it is argued that this is a harsh punitive measure on professionals who are grossly overburdened in their workload. This research is greatly significant as decisions such as that relating to Peter Conolly may have a negative impact on the morale in the profession, causing top professionals to leave the profession and causing an overall shortage of professionals due to the risk of dismissal for factors beyond the control of these workers. The importance of an effective social welfare service goes without saying and therefore regression in this profession is not an option.

Literature Review

The concept of a ‘chilling effect’ is well known in literature, most notably in law for decisions made which may affect the practice of a particular occupation because of the unfair expectations placed on those individuals. This especially is seen in professions in the public sector as often these roles attract greater cries for accountability in the event of a crisis. Often, these kinds of disciplinary actions are a public scapegoat whereby the government can be seen to be taking action, although these actions are often superficial as pointed out by Munro (2011) as they do not account for the cause.

The under resourced implications in the profession of social work is well documented. The consequences of this are enormous placing exceptional strain on these professionals burdening them with excessive administrative duties, an unmanageable caseload and arbitrary forms of accountability and performance review. The recent publication of the State of Social Work (BASW, 2012) has shown statistics relating to the profession that should be regarded as rather alarming given the responsibility that is placed on these professionals for the welfare of the nations vulnerable children. These statistics show that many professionals are highly concerned about the security and financial circumstances relating to their jobs, excessive overburden in workload and dissatisfaction in the roles as a result of the former two factors. There is little doubt that the professional error that formed the basis of dismissal of the social workers in the case of Peter Conolly was a knock-on effect of these resource constraints. Although, as noted in this case, it led to a fatal result it is debatable whether these failures to protect children by the state should be attributed to the professionals or rather whether they should be seen as a larger failure of the institutions and organizations tasked with the protection of children.

Every Child Matters is a government driven initiative which, amongst other things, promotes the integration of various stakeholders in the field of social welfare in order to present a united front line of support staff. This encourages cross organization communication and early intervention. The emphasis on a network of social welfare professionals working together to prevent cases such as Peter Conolly reinforces the debate of whether it is just and fair to attribute the death of a child to one professional individually, as arguably there are many different workers involved in one case. The SCR report on the death of Peter Conolly mentions a wide variety of persons involved in the welfare of the child.

There is some suggestion that other factors should be considered when attempting to attribute accountability to any professional or organization that perhaps was not given enough weight in the case of Peter Conolly. It was noted in the SCR that the mother of baby P. was a well-versed in the social welfare system having grown up in an abusive home and therefore knowing the protocols and factors that were considered in nominating baby P. as a high risk case. The SCR further shows that this mother was often elusive and difficult to get hold of for whatever reason and it can be argued that taking extreme measures in the case of Peter Conolly would have jeopardized other cases that the social worker may have been working on at the time. Although it was classified as a high risk case, the reports from the various parties were that the child was comfortable and happy during home visits and evaluations. It is arguable therefore that the social worker was reasonable in not spending more time and resources on trying to force more home visits on the mother of baby P. Without the value of hindsight, it is arguable that all social workers would like to give parents the benefit of the doubt, as is an occupational hazard. The tragedy of the events should not be judged with this hindsight as it risks being an armchair critic, wise after the events.


The methodology used will be to examine various secondary sources of information relating to the outcomes of SCR for the professionals involved. This will determine whether measures taken against the professionals were extreme in the circumstances, but also whether there is an impact of these SCR on the organizations themselves. The current plans for restructuring of this public sector will also be considered in light of the criticisms raised by the various reports published on the protection of children and the progress made towards those goals. The suggestions forwarded by the Munro report (2011) and the BASW report (2012) will be considered in order to determine whether these suggestions will have a positive impact on the flailing morale and current problems with the social welfare profession.

Conclusion and Recommendations

The purpose of this research is not to suggest that these failures by any part or member of the organization are in any way acceptable. The death of a child due to abuse and neglect is never acceptable in any situation and in all cases there is a need for SCR to determine if there has been professional negligence in failing to intervene timeously leading to the fatal outcome. In the case of Peter Conolly, where an error in professional judgment was held to be the cause, appropriate action must be taken against unqualified and negligent professionals in the industry. However, if these errors and mistakes are as a result of a resource constraint that could be described as unrelated to the competency of the social worker themselves, the organization should shoulder the responsibility for this failure to take appropriate preventative measures rather than chastising the social worker involved for the purposes of public accountability. The morale in this profession is at an all time low as it is and one cannot risk the further demotivation of staff in these organizations as it will lead for further slipping of standards. Expecting social workers to perform competently and adequately in an environment where their workload is far higher than normal, as well as burdening them with extra responsibilities and duties, not to mention the demotivating effect of fiscal change, is unreasonable in the circumstances and will have a negative effect in the long term on the profession of social welfare.

The recommendation therefore will be to revise the disciplinary procedures in SCR in order to firstly determine if there has been a failure of the organization or organizations involved in the case to determine the cause of failure of duty. Such an inquiry should lead to a discovery of professional negligence if such negligence existed in the case. Invariably an examination of the entire procedure and events should yield a fairly conclusive result as to the cause of the failure. Thereafter, any professional failures on the part of a specific social worker or other involved professional should be dealt with in the appropriate manner.

A further recommendation is to reallocate certain resources to these organizations so that certain pressures may be relieved. This may include the assignment of additional administrative staff, inclusion of training in work schedules, the immediate filling of departmental vacancies so as not to overburden the social workers and certain tenure for these professionals as there is a clear concern for job security in these circumstances.


Christou & Ward v London Borough of Haringey [2012] UKEAT 0298_11_2505

Haringey Local Safeguarding Childrens Board, 2009 (Serious Case Review ‘Child A’) (ref: March 2009) London: Department for Education

The British Association of Social Workers, 2012 (The State of Social Work 2012) (Ref: 15/05/2012) London: sn

The Department for Education, 2004 (Every Child Matters: Change for Children) (DfES/1081/2004) London: Department for Education

The Department for Children, Schools and Families, 2010 (Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children) (DCSF-00305-2010) London: Department for Education

The Department for Education, 2011 (The Munro Review of Child Protection: Final Report, A child centred system) (ref: May 2011) London: Department of Education

The House of Commons: The Lord Laming, 2009 (The Protection of Children in England: A Progress Report) (ref: 15 March 2009) London: The Stationary Office