09 February 2021

Identifying risk: An analysis of police practice in statutory reviews of death and significant harm

This is the second of a series of articles by Dr. Debra Allnock about her analysis of reviews of death and significant harm. This article focuses on commonly identified police practice and risk-related themes from analysis of those reviews.

There are national gaps in the way findings from different types of statutory reviews into cases of death, serious harm and neglect are collated, analysed, integrated and disseminated to enable 'whole system' learning. In order to address this gap for policing, the Vulnerability Knowledge and Practice Programme analysed 126 statutory reviews of death and significant harm to explore the ways in which police activity features in these reviews. The analysis has facilitated learning across disparate reviewing systems and multiple forms of vulnerability to synthesise lessons for the police and inform the National Vulnerability Action Plan (VKPP, 2020, V2).    

Following a wide-ranging search of established repositories, safeguarding board websites and requests to forces and third sector agencies, the VKPP scanned over 600 reviews. Using inclusion criteria, most importantly evidence of police engagement with the child, adult and/or their families within the timeline of the reviews, a final sample of 126 was identified. This sample comprised: 69 Serious Case Reviews/ Child Practice Reviews (SCRs in England or CPRs in Wales); 45 Safeguarding Adult Reviews/ Adult Practice Reviews (SARs in England or APRs in Wales); 10 Domestic Homicide Reviews (DHRs); and 2 joint reviews (an SCR and SAR; and a SAR and DHR). 

Identification of vulnerability-related risks

Analysis of these serious case reviews identified themes across a range of policing activity, including the identification and management of risk, victim engagement and care, evidence and investigation and collaborative working. This article focuses on the identification of risk, which was identified as a persistent issue. Three key themes are presented below.

Tunnel vision

There was a tendency in some of the reviews for police to focus predominantly on the reason for their 'call-out', inadvertently overlooking children or adults at risk of harm in the household who were secondary to the initial response. As a result, potential vulnerability-related risks, safeguarding needs and subsequent opportunities to respond and appropriately refer were missed. In the cases where this was identified as a problem, police were often responding to another vulnerability such as domestic abuse or other domestic disturbance.

It is important to recognise that multiple vulnerability-related risks may be present in a location when police respond to calls, and there is a need to be aware of the impact on children and adults of violence or crime occurring in their environments. The College has produced Guidelines* for police responders which advise on clues that indicate vulnerability-related risk in those they come into contact with, highlighting that children and adults may find it difficult to recognise or disclose their own vulnerabilities.  The VKPP analysis indicated that speaking directly to all children and adults in the household, on their own where possible, may help to surface additional safeguarding needs, enabling appropriate referrals and engagement of partner agencies. 

Accepting testimony at face value

Reviews revealed that there were also occasions where officers accepted victim or witness testimony 'at face value', neglecting to question more widely and deeply about what might be going on. This was more common in cases involving adolescents, adults and domestic abuse cases. In examples involving adolescents, officers sometimes appeared to lack awareness of the dynamics of exploitation and the subsequent impacts of this on the ways in which young people report abuse and crime, resulting in wider failures to investigate beyond young people's testimonies.  In other cases, officers appeared to accept young people's circumstances as a result of their own behaviours and lifestyle choices. In cases involving adults, acceptance of repeated behaviours as 'normalised' may have influenced officers' muted responses.  Remedies include the need to exercise professional curiosity, ask questions, maintain an open mind, challenge one's own assumptions and understand one's responsibility to investigate.      

Binary labelling of witnesses and suspects

Police activity, summarised in reviews, sometimes indicated that officers viewed adolescents or adults at risk of harm solely through the lens of a 'suspect/ perpetrator', obscuring their vulnerability-related risks and wider safeguarding needs and responding predominantly with a criminal justice approach. Where a crime is committed, police must of course appropriately initiate criminal justice responses. However, reviews reinforced the importance for police in keeping an open mind, being professionally curious, avoiding binary labelling of 'victim or suspect/perpetrator' and ensuring any discovery or disclosure of illegal activity does not undermine the potential for simultaneous experiences of victimisation.  For example, Ofsted ** says that children criminally exploited who may be found in possession of a weapon or Class A drugs should  be treated first and foremost as safeguarding subjects.  Safeguarding interventions should be considered which reduce risk to others, but consideration should always be given to making safeguarding referrals so that safeguarding needs can be investigated and addressed.  


This article has provided insights into, and pointers for practice about the identification of vulnerability-related risk by the police, as it features in cases of death or significant harm. The research found practice can sometimes be constrained by 'tunnel vision', accepting testimony at face value, and binary labelling of adolescents and adults at risk of harm which means that their vulnerabilities to victimisation themselves may be hidden. The next article in this series will consider insights from statutory reviews into victim engagement and care.  All related publications and methodologies can be found at the Knowledge Hub or on the College of Policing Vulnerability and Violent Crime web page. 

Dr Debra Allnock is a social researcher from the University of Bedfordshire and is working with the Home Office funded Vulnerability Knowledge and Practice Programme (VKPP).


*College of Policing (forthcoming 2021) Evidence-based guidelines: Recognising and responding to vulnerability-related risks.  London: College of Policing. 

**Ofsted (2018) Protecting children from criminal exploitation, human trafficking and modern slavery: an addendum.  London: Ofsted.