Social Policy Journal of New Zealand, March 2007, 30: 1-11

Reviews of maltreatment deaths of children known to child protection authorities spring from a desire to improve practice and enhance safety for children. As such, they may be failing their core purpose. This article explores the use made of such reviews and how limiting our learning to these tragic events may have unintended consequences in terms of building strong systems of support for children. It is argued that the risk-averse systems that can result from political and organisational responses to child death reviews have the potential to impact negatively on services for at-risk children. A systems framework is proposed as a more productive way of exploring the complex and multi-faceted aspects of case work invariably associated with these tragic events. A systems analysis provides a change of focus from the conduct of an individual social worker, by extending examination across a set of related dimensions - the family system, the worker system, the organisational system and the wider system. The authors conclude that child death reviews that place practice in a wider context are more likely to contribute positively to the strengthening of services for children overall.--AUTHOR'S ABSTRACT