Abstract

Abstract In most child protection jurisdictions, a case of child death or serious injury through the actions or inaction of a parent or carer is responded to with an inquiry into the circumstances that led to the death of the child. A key objective of such inquiries is to discern what may have been done by public agencies to prevent the child’s death or serious injury and this may, in turn, lead to changes in existing policies or the development of new policies. Such changes have, at times, been criticised as ‘knee jerk’ reactions and can lead to well-meaning but possibly counter-productive initiatives. A general observation is that, in some inquiry reports, there is little, if any, reference to research and theory about child protection practice and policy. In this article, an anonymised case study of a child death inquiry is used to analyse the decision-making processes of child protection practitioners using a range of theory and research. The aim is to demonstrate how the use of insights from theory and research can lead to an enhanced understanding of the circumstances that led to a child death or serious injury, one which is grounded in current knowledge and evidence.

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