D uring the 1970s and 1980s, a small number of fatal child abuse cases which had aroused public concern became the subject of public inquiries. Although the inquiry panels' recommendations undoubtedly contributed to policy developments over the years, we have questioned whether the ยฎndings made a lasting impact upon day-to-day practice in certain crucial areas and have suggested that the beneยฎts of the inquiries were outweighed by their limitations (Reder, Duncan and Gray, 1993;Reder and Duncan, 1996). One signiยฎcant problem was that the inquiries had tried to encompass multiple incompatible agendas, including to ascertain whether workers were negligent, to reยฏect on any lessons to be learned from the cases, to reassure the public that the state monitors such events and to provide opportunities for catharsis.
Working Together (Department of Health and Social Security & Welsh Oce, 1988) contained revisions to procedures for reviewing cases in which a child had died from abuse and these were further reยฎned in Part 8 of the document's updated version (Home Oce, Department of Health, Department of Education and Science & Welsh Oce, 1991). This made provision for local reviews of cases which had involved the death of a child from abuse or where concern had arisen about child protection issues. An individual review was to be undertaken by each agency, followed by a composite review by the Area Child Protection Committee, with the ยฎnal report submitted to the Department of Health.
The Department of