Child death inquiries Moving beyond the rhetoric of learning

The process of reviewing deaths of children who had formerly been known to a child protection agency is emotive, and its value is often contested. This paper is written with the frontline practitioner in mind, and grapples with the complexities of how inquiries can make a difference in the world of all relevant stakeholders. It is contended that a goal of individual and systemic learning can be achieved if inquiries take place in a healthy, collaborative learning culture, if they are embedded in a multi-sectoral systemic framework, and if a reflective analysis is undertaken. Such inquiries would prioritise an understanding of the individual, organisational and systemic factors that influence thinking, feeling and doing. When constructed and experienced as opportunities for individual and collective learning, inquiries have the potential to add value to the whole service system and the practice of frontline workers, along with meeting the need for public accountability.