SCOPE OF THIS CHAPTER
This chapter covers the requirements within chapter 4 of Working Together to Safeguard Children 2015, which describes the way Serious case Reviews should be initiated and scoped and the principles to be used when undertaking Serious Case Reviews, as well as other forms of reviews and audits.
Serious Case Review Quality Markers. This guidance cover all stages of the Serious Case Review process from Initial Referral through to Implementation and Evaluation of learning following a Review. They include principles of good practice and are designed to help commissioners and reviewers achieve high quality reviews.
This chapter was updated in November 2016 to include the link to Quality Markers.
- Serious Case Review Process
- Referral of a Case to the Serious Case Review Panel / Serious Incident Review Sub Group
- Decisions Whether to Initiate a Serious Case Review
- Principles of Serious Case Reviews
- Methodology for Learning and Improvement
- Commissioning the Review
- Information Sharing / Consent
- Timescale for Serious Case Review Completion
- Serious Case Review Process
- Reports and Publication
- National Panel of Independent Experts on Serious Case Reviews
1. Serious Case Review Process
The LSCB must undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 set out the LSCB's function in undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.
A Serious Case Review must always be initiated when:
- Abuse or Neglect of a child is known or suspected; AND
- The child has died; OR
- The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.
Thus cases meeting either of these criteria must always trigger a Serious Case Review:
- Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
- Abuse or Neglect of a child is known or suspected AND the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In this situation, unless it is clear that there are no concerns about inter-agency working, a Serious Case Review must be commissioned.
Additionally, even if these criteria are not met a Serious Case Review should always be carried out when:
- A child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children's home or where the child was detained under the Mental Health Act 2005.
1.2 Referral of a Case to the Serious Case Review Panel / Serious Incident Review Sub Group
- A referral to the Serious Case Review Standing Panel (SCRSP) / Serious Incident Review Sub Group (SIRSG) can be made by any NCSCB / NSCB Partner organisation with the agreement of their NCSCB / NSCB Representative;
- Partner organisations making a referral for an SCR have a responsibility to quality assure the referral prior to sending it through to the NCSCB / NSCB and to compare it to the criteria for SCRs in Working Together 2015. If the case meets the criteria for an SCR the referral should be made to the NCSCB / NSCB Board Manager / Officer in writing;
- SCRSP / SIRSG can commission an alternative review from relevant organisations involved. In both cases, the Project Plan and the learning and action plan arising from these should be forwarded to the SCRSP / SIRSG for information / monitoring;
- All cases where a child has died or suffered a potentially life threatening injury, serious sexual abuse or sustained serious and permanent impairment of health or development; and abuse or neglect are known or suspected should be notified to Ofsted using the serious incident notification electronic link. All these cases should also be considered by the SCRSP / SIRSG, with a referral made by an agreed organisation;
- Referrals should be made on agreed referral form (see SCR Referral Form) and sent to the appropriate Board Manager / SCRSP / SIRSG through the NCSCB / NSCB Business Office by secure e-mail;
- Referrals from Child Death Overview Panel (CDOP) should be made by the CDOP Chair and sent to the Chair of the SCRSP / SIRSG by the same route;
- Where the case appears to meet the criteria for an SCR, prior to consideration at the SCRSP / SIRSG, information will be gathered from each organisation involved with the child and their family to enable robust decision making. This will be undertaken using the Information Gathering form (see SCR Initial Request for Information Proforma) which will be sent to the LSCB organisational representative by secure e-mail. There will be occasions where full information gathering is not required but this decision should be made / ratified by the SCRSP / SIRSG.
1.3 Decisions Whether to Initiate a Serious Case Review
- The SCRSP / SIRSG will consider the case within a month of receipt of the referral, where the date the referral was received makes this practically possible. Alternatively the next SCRSP / SIRSG will be notified of receipt of a referral and the case considered at the following panel;
- The decision by the NCSCB / NSCB Independent Chair will be communicated to the SCRSP / SIRSG within 14 days of the recommendation being sent to the Independent Chair;
- Where the decision is that a SCR will be commissioned the NCSCB / NCSB Board members will be notified;
- Ofsted and The Department for Education will also be informed of the decision within 14 days. The NCSCB / NSCB Independent Chair will inform the National SCR Panel about SCR decisions on all cases notified to Ofsted as well as any other cases referred for a SCR;
- Where an SCR has been agreed, the names of the reviewers appointed to undertake the review should be sent to the national panel with the decision. If a SCR has not been agreed the Serious Incident Notification (if available, if not, brief case information) and the explanation for why the case does not meet the SCR criteria should be sent.
If the Serious Case Review criteria are not met, the LSCB may still decide to commission an alternative form of case review.
1.4 Principles of Serious Case Reviews
All Serious Case Reviews will:
- Be led by an appropriately trained Independent Chair / Reviewer;
- Focus on learning and not blame, recognising the complexity of circumstances professionals were working within;
- Be proportionate according to the scale and level of complexity of the issues being examined and transparent about the way decisions are made and data is collected and analysed;
- Develop an understanding who did what and the underlying reasons that led individuals and organisations to act as they did;
- Seek to understand practice from the viewpoint of the individuals and organisations involved at the time and identify why things happened;
- Include involvement of family members where possible and appropriate;
- Be inclusive of all organisations involved with the child and their family and ensure information is gathered from frontline practitioners involved in the case;
- Include individual organisational information from Internal Management Reviews / Reports / Chronologies and contribution to panels;
- Make use of relevant research and case evidence to inform the findings of the review;
- Identify what actions are required to develop practice;
- Include the publication of an SCR Report;
- Lead to sustained improvements in practice and have a positive impact on the outcomes for children and families.
1.5 Methodology for Learning and Improvement
Working Together 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the principles set out in 1.4.
Some Examples of Models which may be considered
- SCIE Learning Together* (LT) has been piloted and evaluated during the Working Together consultation period **and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved;
- Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened; ***
- Child Practice Reviews **** replaced the Serious Case Review system as the statutory guidance in Wales on 01.01.13, This process consists of several inter-related parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an Extended review which involves an additional level of scrutiny of the work of the statutory agencies;
- Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a 'Learning Event' and 'Recall Session';
- Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR's conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong. They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.
Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Learning and Improvement Framework Procedure, Purpose of Local Framework, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.
Learning and actions for improvement identified from the process, will be disseminated through the locally agreed Learning and Improvement Framework detailed in Learning and Improvement Framework Procedure.
1.6 Commissioning the Review
- The SCR will be commissioned through the SCRSP / SIRSG. This will include agreeing:
- The scope and Terms of Reference of the review using the appropriate form;
- An Independent Reviewer / Chair / Author who is suitably qualified / experienced to lead the review and organisation representatives for the SCRSP / SIRSG;
- Which organisations are required to contribute chronologies and the timescale for this;
- Consideration of the requirement for agencies to submit Individual Management Reviews (IMRs) / Reports and the timescales for these;
- SCRSP / SIRSG members who are senior representatives of organisations involved with the child and their family, or required to support the panel with additional information / advice;
- The level of involvement by practitioners involved in the case.
- The model for the SCR should be considered and agreed at this point, along with the identification of IMR / Report Authors and their involvement in the process;
- The impact and timing of any parallel processes on the review must be acknowledged at this stage. Police advice must be sought in relation to the potential impact of the SCR and talking to practitioners / managers involved in the case where there is a criminal investigation or the potential for one. Liaison with the Coroner must be undertaken throughout the SCR when there is potential for an inquest;
- Where other LSCB areas have been involved in the provision or services to the family, liaison between LSCB Managers will be undertaken to commission chronologies, reports and panel representatives as required. In some circumstances (for example where there is significant involvement of 2 or more LSCB 's consideration should be given to undertaking a joint SCR;
- A Briefing Session will be held to support partner organisations involved within the review to share information on the case; the Terms of Reference and the process of the SCR (including timescales) including how practitioners will be engaged within the process;
- The LSCB will provide the National Panel of Independent Experts (see Section 1.11, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.
1.7 Information Sharing / Consent
- Clarity on the legislative framework for sharing information to make a decision about whether a case meets the criteria for an SCR and to undertake the SCR will be included in the initial request for information from agencies. Working Together 2015 sets out a requirement for persons and bodies to comply with a request for information, any such request will be necessary and proportionate;
- Once a SCR has been agreed, consideration of the legislative framework to share information within the process will be undertaken by the SCRSP / SIRSG;
- Agreement on the involvement of the family is to include:
- At what point the parents / families will be informed of the SCR (specific family members will be identified and agreement about who will be identified, when and by whom);
- Issues in relation to consent and Public Interest including the impact of criminal, coronial and care proceedings on the ability to liaise with the family;
- Inclusion of their views of the support provided to them by organisations;
- Inclusion of their views on the findings of the review;
- The impact of publication of the SCR Report;
- Feedback to inform them of the progress of the SCR.
- The agreements must be clearly recorded within the Terms of Reference.
1.8 Timescale for Serious Case Review Completion
The LSCB will aim for completion of the Serious Case Review within six months of initiation. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:
- Capture points from the case about improvements needed; and
- Take any corrective action identified as required.
1.9 Serious Case Review Process
- Chronologies will be requested from all organisations involved with the child and their family using the agreed template;
- IMRs / Reports (on the agreed template) A decision on the use of IMR's or similar report submission will be made on a case by case basis; and be dependant on the review method identified. In some cases they may not be used at all in others they may be requested from organisations with relevant and significant involvement with the child and their family. If an organisation had only minimal involvement with the family and this wasn't connected to the Terms of Reference for the review, consideration will be given to the requirements for them to complete a background report or just a chronology;
- The First Panel will be used to develop a narrative of the case, ensuring a common understanding of the sequence of events and key practice issues. IMR authors and Panel members will be invited to this meeting;
- Quality Assurance of the IMRs / Information Reports will be undertaken using an agreed process that ensures they include adequate information and reflect the terms of reference. This will include consideration of the organisation action plans. Agencies should take responsibility for quality assuring reports prior to submission;
- The Second Panel (and subsequent panels if required) will be used to analyse the case based on the narrative and key practice issues. All panel members should be invited to attend, along with IMR authors if appropriate.
- Subsequent Panels will be required to identify key learning from the review, as well as ensuring information on the context of the case, good practice, research and changes in practice are identified and included within the SCR Report.
1.10 Reports and Publication
In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB's website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.
The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication 'will not be likely to harm the welfare of any children or Vulnerable Adults involved in the case' and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.
The final Serious Case Review report will:
- Be fully anonymised to ensure the child and any siblings are not identifiable;
- Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
- Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
- Be suitable for publication without needing to be amended or redacted.
Ratification of the SCR Report will be undertaken in multi agency forums through the NCSCB / NSCB structure. Key Learning should be identified within the SCRSP / SIRSG to enable the formulation of appropriate recommendations and an action plan.
The SCRSP / SIRSG will be responsible for agreeing the SCR Recommendations and Strategic Action Plan, along with the SCR Report prior to presentation to the NCSCB / NSCB Strategic Board.
The NCSCB / NSCB Strategic Board will be responsible for the ratifying all SCR documentation prior to submission to the Department for Education.Publication will be carefully planned depending on any parallel processes (criminal and coronial) and family contributions and the national SCR Panel will be consulted for advice and guidance.
The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:
- Actions already taken in response to the review findings;
- The impact these actions have had on improving services; and
- What more will be done.
The LSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, it should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.
A media strategy will be developed to support publication and the management of any media enquiries.
1.11 National Panel of Independent Experts on Serious Case Reviews
Working Together to Safeguard Children introduced a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews. The panel will report to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel's advice on:
- Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
- Appointment of reviewers;
- Publication of Serious Case Review reports.