Safeguarding Children living with Foster Carers, Adopters and Special Guardians: Learning from case reviews 2007–2019

Safeguarding Children living with Foster Carers, Adopters and Special Guardians: Learning from case reviews 2007–2019


Case reviews have played a critical role in helping organisations to improve the safeguarding of children. Since 1988 in England and Wales, where a child has died or come to serious harm, and abuse or neglect is known or suspected, local case reviews have provided useful explanations that can contribute to learning and change.

This good practice guide is based on a UK-wide study of 52 case reviews concerning 98 children who had died or experienced serious harm while living with foster carers, adopters or special guardians. The study spans a 12-year period and is the first to focus exclusively on reviews of cases of children in alternative family care. Consequently, it shines a spotlight on those issues that are particular to these children – the selection and assessment of their carers; the support both children and carers receive; and the supervision and management of such arrangements.

The ability to change and improve practice is dependent on understanding why particular mistakes or failures occurred and learning from them. Various factors, relating to organisational culture, systems and practice, can hinder practitioners and organisations from safeguarding children effectively. This study explores the reviews to identify recurring themes and draws out the dilemmas and challenges for practitioners in carrying out their responsibility to promote and safeguard the welfare of children.


Who is this book for?

This is a vital resource for social work practitioners and managers, panel members, commissioners, and all those involved in the care of looked after and adopted children.

What you will find in this book

The guide explores the issues of concern and dilemmas identified as occurring repeatedly in the case reviews, including:

  • the assessment and selection of carers: exploring motivations, gaps in information, sensitive issues, carer attitudes, and managing doubt and uncertainty;
  • keeping the child at the heart of practice: improving placement planning and preparation, reviewing children’s well-being, listening to children and considering their views, and closely monitoring very vulnerable children;
  • supporting carers: the level of supervision and oversight, organisational pressures and their impact, maintaining objectivity;
  • being aware of the assumption of safety in foster care and adoption: reluctance to explore unease, asking questions about an absent child, avoiding manipulation, and maintaining authority;
  • effective communication and collaboration: between agencies, including health, social care and education, and clarity about responsibilities to share information between services and across local authority boundaries.

Rich with case examples and quotations from the reviews studied, the findings form an authoritative guide as to what can be done in day-to-day social work to reduce the risk of significant harm and child death.

To make the knowledge from this study more readily accessible, a short companion guide has been developed

Read the contents page and introduction

About the authors

Dr Hedy Cleaver is an Emeritus Professor at Royal Holloway College, University of London. Her experience as a social worker and child psychologist informs her research on vulnerable children and their families and the impact of professional interventions. Most recently, she was part of the research team responsible for the last triennial review of serious case reviews (Brandon et al, 2020). The guiding principle underpinning her work is a desire to improve the quality of life for children living in circumstances that place them at risk of abuse and neglect. The findings from her research have had an identifiable impact on policy and practice in the UK in respect to children and families throughout the last 30 years.

Wendy Rose OBE held children’s policy responsibilities at the Department of Health as Assistant Chief Inspector, following social work and senior management experience in the NHS and local authority. At the Open University as a Senior Research Fellow, she worked on research and development projects. During this time, she acted as a professional adviser to the Scottish Government on developing its children’s policy, Getting it Right for Every Child. Latterly, she worked with the Welsh Government on its safeguarding reforms and as an Honorary Research Fellow at Cardiff University. She has published widely including, with Julie Barnes, the second biennial analysis of serious case reviews, Improving Safeguarding Practice, for the Department for Children, Schools and Families (2008).


This title is now available in digital-only format for immediate access. Purchases are held in your own personalised online library and accessed via your browser or through the app on your phone or tablet.

Questions about eBooks? Check out our FAQs


A 10% bulk order discount will be applied at the checkout for orders of 10 copies or more on this title.



This guide is well laid out and, despite the complexities of the subject matter, it is an accessible read for all involved in keeping children safe. We will be recommending this guide through our work with practitioners as well as to adoption, fostering and kinship panel members.

Ravinder Kaur and Maggie Grant, British Journal of Social Work

This study aims to help practitioners adapt their practice in order to keep children placed away from home safe from death or significant harm. This book would be of use to those involved in the assessment and support of adults providing care for a child through one of these arrangements, as well as those involved in the placement review process. It is written in a clear and accessible manner, bringing a fresh perspective to the information that has been gathered across a range of serious case reviews.

Alex Jennings, Independent Social Worker