10 February 2020

Reviewing the reviews: How to maximise learning from adverse incidents to improve police responses to vulnerability

Dr. Debbie Allnock is a social researcher at the University of Bedfordshire and is working on the Vulnerability and Violent Crime Programme. Here she discusses her work examining police practice in a range of reviews of significant harm and death.

What was the background and scope of the research? 
The Vulnerability Knowledge and Practice Programme within the VVCP recognised a gap in learning from adverse incidents/learning lessons reviews for the police. These include serious case reviews (SCRs) and safeguarding adult reviews (SARs) in England, adult practice reviews (APRs) and child practice reviews (CPRs) in Wales, and domestic homicide reviews (DHRs). While there has been some previous analysis of SCRs, SARs and DHRs*, few have focused on police practice specifically, and only one known study considered learning for agencies across multiple review types**. 

The purpose of this research was to collectively learn insights from these reviews into police practice and identify how police can be supported to improve their responses to children, young people and vulnerable adults across a range of vulnerabilities, often, where there are multiple vulnerabilities present.  We analysed 124 reviews in total, including 69 SCRs/CPRs, 45 SARs/APRs and 10 DHRs.  A full methodology for each review type can be found in the appendices of their associated briefings here.    

What were you looking for?
Having identified reviews that were potentially relevant, we screened them against a set of 'inclusion' criteria.  This included published reviews where police had been engaged with the child or adult and/or their family members prior to their death or experience of significant harm.  We often hear from police colleagues that, upon publication of reviews, the first instinct is to go straight to the recommendations to see what is relevant for the police.  For this research, we focused on the narrative content of the reviews, searching for any description of police involvement and its context for analysis. The extracts were then coded thematically against broad areas of police practice such as multi-agency working, information sharing, risk assessment, evidence and investigation, and supporting victims. Taking a 'systems' approach, we sought to identify environmental or organisational explanations for missed opportunities or points at which police practice did not meet expected standards.   

How did the template help you to analyse the varied reviews?

We developed a template to support consistent and targeted data collection across a variety of types of reviews which are written differently and underpinned by different methodologies. The template helps to keep those reviewing the reviews focused on police practice and, importantly, on the reasons why there were missed opportunities.  In addition to collating specific characteristics of the case, we were particularly interested in:

  •  The description of police involvement (how and why were they involved?)

  • A description of police practice (what did they do – or not do?)

  • The reasons for missed opportunities or practice which did not meet expected standards (what impacted on this?)

  • Good practice or solutions to missed opportunities (what did they do well?). 

Analysing the narrative accounts of practice in this way provides a different perspective than only focusing on the recommendations presented at the end of the reports. What we found was a richness of information about police practice contained within the reviews; much of which never makes 'the cut' into targeted recommendations for the police.  When we only look for relevant recommendations for the policing sector, there is a risk that a host of other practice that is worthy of consideration is missed (even if the reviewer did not consider it serious enough for a recommendation).  Having analysed multiple reviews in this way, the 'hidden' practice within the reviews accumulates and we find similar patterns.  So far, our template has been used to analyse SCRs, SARs and DHRs.  We don't yet know if it is suitable for collecting information on practice contained in other types of reports; but we anticipate that the template could be adapted for use on different types of reviews.  

What are the common weaknesses in review reports?
Reviews vary in quality. Reviewers use different approaches and methodologies and have varied experience and skills.  The level of detail relating to police practice included in reviews is wide-ranging, as is the quality of information provided.  For example, sometimes a reviewer will describe 'what went wrong', but the description lacks sufficient contextual information to make an assessment, with little or no exploration of why things went wrong.  As a result, it can be hard to tailor and target appropriate recommendations for the police.  Despite this, the learning can be used to facilitate reflection on practice to understand whether similar things could happen again and/or in other forces.    

What will this work contribute?
This is the first known piece of work that focuses solely on police practice by drawing together collective learning in relation to vulnerability, from multiple review types.  Up to now, we have published briefings on individual review types; in 2020 we will publish a report which collectively analyses practice across all 124 reviews to understand cumulative and comparative learning.

How can future reviews improve to ensure learning has the best impact?
Historically, SCRs/CPRs and SARs/APRs have been focused on the social care and health sectors; this may well explain why there is typically less attention given to police practice.  However, statutory guidance on these reviews does not preclude learning for police; in fact all guidance refers generically to 'how agencies work together'.  Given the new children's safeguarding arrangements that establish police as an equal partner in safeguarding, and more widely the shift in policing towards enhanced focus and responses to vulnerability, there is a case for improving what can be learned from reviews about the ways in which police feature in these cases.   

Our tips to reviewers are to:

  • Give equal attention to the police contribution to the case, where relevant. Police do not always play a significant role, but even where they don't we have found even minor errors or missed opportunities to be worthy of reflection
  • Try and understand what underpinned missed opportunities or errors by police and report this with clarity.  It may not always be clear, but knowing exactly what went wrong assists in targeting recommendations and support to police.
  • Include better descriptions of good practice or what police did to respond to the review findings, where possible.  We acknowledge these reviews tend to be deficit-focussed but well-articulated good practice can be used to offer solutions to the police.