The Importance of Keeping Records

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Social work is a formal activity, with outcomes which may be of enormous significance to service users and others.  Much of this activity relies on the successful gathering, understanding, sharing and giving of information.  While in the first instance the gathering and sharing of information may rely on high quality verbal communication and interpersonal skills, it usually needs to be captured and codified, ie recorded, in some form if it is to be a useful tool of high quality service delivery.

The importance of  good quality recording, at every stage of social work practice and service delivery, cannot be overstated.   Every inquiry into major instances of failure to protect a child has pointed to communication and recording defects as a major factor.  For instance,  consider the following extracts from Lord Laming’s report into the death of 7 year old Victoria Climbie (www.victoria-climbie-inquiry.org.uk/finreport ):

  • In some cases nothing more than a manager reading a file, or asking a straightforward question about whether standard practice had been followed, may have changed the course of these terrible events. (para 1.17)

 

  • The tragic consequence of this was that nobody in Haringey - not even [the social worker] - ever read Victoria's case file in its entirety. (para 6.59)
  • We cannot be certain what passed between the two because of the lack of recorded information - indeed in the case of the hospital there was none whatsoever - or whether Ms F simply misunderstood what Dr F was saying. (para 6.177)

 

  • However, it is unlikely that Ms R read any of this material because she said she found it illegible and "could not read it". Regrettably, she made no attempt to ask the Central Middlesex Hospital for help in clarifying its contents. If she had, she would have learned that ………. The medical report identified that there were scars of various sizes and ages all over the body from two days to possibly months old. There were also fresh scars on the face, infected cuts on the fingers and bloodshot eyes…. (para 6.185)
  • Resolving this conflict of evidence has not been helped by Ms K’s poor note taking. There is certainly no record of a telephone conversation between Ms A and Ms K in Ms A’s contact notes on Victoria's case file.(para 6.284)

 

The deficiencies in this case involved communication between social workers and their line managers, other social workers, the police, doctors and nurses.  (Many of these other professionals also had poor or non-existent systems for recording key facts and conversations.)   Although bad recording was not the only factor that led to the failure to protect Victoria from a terrible death, it was a significant one, which Lord Laming described as:the dreadful state of communications which exposed Victoria to danger (para 1.43).
Elsewhere he asserts: The case file is the single most important tool available to social workers and their managers when making decisions as to how best to safeguard the welfare of children under their care. It should clearly and accessibly record the available information concerning the child and the action that has been taken on the case to date. Reference to the case file should be made at every stage of the case and before any significant decision is made.(para 6.623)


Accurate, accessible and detailed recording is not only essential in Child Protection cases; it is a vital tool for ensuring accuracy of information, clarity of goals, accountability, and continuity in all social work with all service user groups.  Of course, it can achieve none of these aims if it is never read, and so in the first place it must be legible.  Laming also identified a number of systemic failures in the importance the organisations concerned attached to recording and reading files, and individual social workers may not be well placed to address such problems.  However, it is every social worker’s professional responsibility to ensure that, at the very least, their own practice, including conversations, is adequately and accurately recorded, and that they are well versed in the information available on their own cases.