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11.1 Learning and Improvement Framework (LIF)


This chapter reflects the importance of a learning and improvement culture within the agencies involved in children's social care and safeguarding. It identifies the key principles that should be upheld and cases that should be subject to Serious Case Reviews, also acknowledging that where concerns don't meet this threshold, agencies should undertake their own learning. Emphasis is made with respect to transparency of the learning processes and feedback in a variety of ways; 'learning' will come from a number of sources, in a number of ways, (identified in Appendix 1: Learning and Improvement Index).


Working Together to Safeguard Children

NSPCC, Serious Case Review Quality Markers, (2016)


This chapter was updated in February 2017 to provide updated and new links: LSCP Learning Improvement Framework (LIF) (see Section 1, Introduction) and new Appendices:

A link has also been added to the NSPCC, Serious Case Review Quality Markers, (2016) for reference.


  1. Introduction
  2. Principles for Learning and Improvement
  3. Responsibility for Undertaking a Serious Case Review
  4. Role of the LSCP Critical Incident Group (CIG)
  5. Role of the Merseyside Child Death Overview Panel (CDOP)
  6. Reviews and Audit Activity
  7. Other Sources of Learning
  8. Role of the LSCP Committees in the Dissemination of Learning

    Appendix 1: Learning and Improvement Index

    Appendix 2: LSCP Critical Incident Group Process - Flowchart

    Appendix 3: LSCP Process: Responding to Cases that May Warrant the Undertaking of a Serious Case Review

    Appendix 4: LSCP Serious Case Review: Request for CIG Consideration Form (CIGSCR1)

    Appendix 5: Learning and Improvement Framework – Activities

1. Introduction

Responsibility of the Local Safeguarding Children Partnership

Working Together to Safeguard Children requires that all Local Safeguarding Children Partnerships maintain a local Learning and Improvement Framework (LIF).

This Learning and Improvement Framework should:

'enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result.'

(Working Together to Safeguard Children, Ch 4 (3))

Working Together requires that the local framework should 'cover the full range of reviews and audits which are aimed at driving improvements to safeguard and promote the welfare of children'.

The LSCP Learning and Improvement framework has been developed to ensure that LSCP partner organisations and agency individuals are clear about what needs to be learnt, where services and practice improvement is required and how any programme of action will lead to sustainable improvements. Integral to the success of this framework will be the sharing of learning on a wide area basis to ensure transparency, accountability and consistent improvement to practice.

Learning and reviewing opportunities in Liverpool will be transparent so that they identify promptly the need for any systemic or organisational changes and ensure timely action is taken. This will ensure that professionals, in all services working with children and families, are given the assistance they need so that they can undertake the complex and difficult work of protecting children with confidence and competence.

The processes highlighted within this framework, including those used for learning, the findings from reviews and improvement activity initiated, are intended to provide assurance to children, families and other relevant stakeholders of the activity, undertaken by the partnership of LSCP, to improve the effectiveness of safeguarding services in Liverpool.

Responsibility of Organisations

All single agencies/partner organisations should ensure that they are aware of the findings from local reviews that are made available from Liverpool Safeguarding Children Partnership and should use this Learning and Improvement Framework to inform Single agency Learning and Improvement activity.

Responsive Learning

LSCP's LIF is updated on a regular basis. It is a responsive document and should be reviewed by organisations, practitioners and all staff regularly so they fully understand of current learning to inform practice.

Click here to view the Liverpool LSCP Learning & Improvement Framework (LIF).

2. Principles for Learning and Improvement

The following principles outline the outcomes Liverpool LSCP and partner agencies should achieve through the process of conducting case reviews, practitioner forums and audits. These outcomes will be placed in the context that any system, including safeguarding systems can only manage and reduce risk, not eliminate it and that systems are made up of numerous variables that constantly change and fully appraising and managing risks of each variable is a complex task.

  • There should be a culture of continuous learning and improvement across organisations, identifying opportunities to draw on what works and promote good and effective multi-agency practice;
  • Learning and reviewing methods recognise the complex circumstances in which professionals work together to safeguard children – as much effort in the process of reviewing should go into identifying and analysing areas of good practice as well as practice that requires improvement;
  • Learning and reviewing methods are transparent in the way they collate and analyse data and make use of research and evidence to inform findings;
  • The approach taken to learning and reviewing should be proportionate to the scale and complexity of the issues being examined;
  • Professionals must be involved in learning and reviewing opportunities; contributing their perspectives without a fear of being blamed for actions taken in good faith;
  • Families, including children (where possible) should be invited to contribute in learning and reviewing opportunities; there should be clarity of how they will be involved and their expectations should be managed appropriately and sensitively;
  • Serious Case Reviews should be led by one or more persons who are independent of the case being reviewed and the organisations whose actions are being reviewed;
  • There is transparency with professionals, family and the public in disseminating the learning; final Serious Case Review reports will be published and findings from all other reviews, practitioner forums and audits will be summarised in LSCP annual reports.

3. Responsibility for Undertaking a Serious Case Review

Regulation 5 (1)(e) and (2) of the Local Safeguarding Children Partnerships Regulations 2006 sets out an LSCP's function in relation to serious case reviews, namely:

5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

(2) For the purposes of paragraph (1) (e) a serious case is one where:

  1. Abuse or neglect of a child is known or suspected; and
  2. Either —
    1. The child has died; or
    2. 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.

“Seriously harmed” in the context described below and regulation 5(2)(b)(ii) above includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCPs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

In addition, even if one of the criteria is not met, an SCR 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 secure children's home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

4. Role of the LSCP Critical Incident Group (CIG)

The LSCP CIG group, comprising of senior managers from partner agencies, has responsibility for considering cases referred to them. Primary responsibility of the group is to rigorously review agencies' contact and interventions with a child and family and consider as to whether a case satisfies the statutory criteria for initiation of a Serious Case Review.

The Critical Incident Group (CIG) meets on a monthly basis to review cases referred to them for consideration. A request to agencies for further information will have been made by the LSCP Administrator in advance of this meeting.

Following consideration of information from each of the partnership agencies, or their representative, the Chair of the CIG advises the independent Chair of LSCP, as to the group's recommendations; to initiate a Serious Case Review (SCR);  to initiate another review (see Appendix 5: Learning and Improvement Framework – Activities), or undertake specific multi / single agency-actions. The final decision to initiate a SCR rests with the independent chair of LSCP.

The Independent Chair of the LSCP confirms, in writing, his/her decision as to whether a serious case, or other review, should be initiated. Immediately following the decision being made, the LSCP notifies Ofsted as to the decision of the independent chair.

Decisions on whether to initiate a Serious Case Review will be made within one month of the LSCP being notified of the incident triggering the threshold.

Who Can Refer a Case to the LSCP Critical Incident Group?

Any professional can refer a case for review to the LSCP Critical Incident Group. If, following review with their agency safeguarding lead or LSCP CIG group representative, a professional considers that a case requires consideration by the LSCP CIG, the agency safeguarding lead should refer a summary of the case using the 'LSCP Process: Responding to Cases that May Warrant the Undertaking of a Serious Case Review' (CIGCON1) (see Appendix 3: LSCP Process: Responding to Cases that May Warrant the Undertaking of a Serious Case Review) to the LSCP administrator Jacqui Taylor:

The LSCP notifies the Independent Chair of SCB, LSCP Business Manager and Chair of the Critical Incident Group.

Reviews Other than Serious Case Reviews

Where cases do not meet the criteria for initiation of a Serious Case Review, the Critical Incident Group will consider whether an alternative review is required.

Different types of review considered by Liverpool LSCP include:

  • Review of a child protection incident which falls below the threshold for an SCR; and
  • Review or audit of practice in one or more agencies.

Further information about Multi Agency procedures for Serious Case reviews can be found: see Serious Case Reviews Procedure.

Serious Case Review – Publication

Working Together to Safeguard Children, Serious Case Reviews requires that 'All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCP's website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be 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.'

Final LSCP commissioned SCRs are published alongside the LSCP's response to the review findings in order to achieve transparency. The impact of SCR's, other reviews and wider LSCP Learning and Improvement activity in relation to improving services to children and young people and on reducing the incidence of deaths or serious harm to children will be described in the LSCP Annual report.

5. Role of the Merseyside Child Death Overview Panel (CDOP)

Local Safeguarding Children Partnership is responsible for ensuring that a review of each death, of a child normally resident in the LSCP's area, is undertaken by a Child Death Overview Panel.

Merseyside Child Death Overview Panel (CDOP) involves all five Merseyside LSCPs; Knowsley, Liverpool, St. Helens, Sefton and Wirral. Merseyside CDOP analyses any deaths occurring in children, aged from new born up to eighteen years old, and identifies any modifiable factors that could highlight areas for future improvement. Merseyside CDOP is responsible for reviewing deaths from the larger population across Merseyside in order to ensure it is better able to identify significant recurrent contributory factors.

Merseyside CDOP a core membership drawn from organisations represented on the LSCP with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. Merseyside CDOP also includes a professional from public health as well as child health.

In reviewing the death of each child, the CDOP will consider modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.

Merseyside CDOP is responsible for:

  1. Collecting and analysing information about each death with a view to identifying:
    1. Any case giving rise to the need for a review mentioned in regulation 5(1)(e);
    2. Any matters of concern affecting the safety and welfare of children in the area of the authority;
    3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
  2. Putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death (Working Together to Safeguard Children, Ch 5).

6. Reviews and Audit Activity

Liverpool SCB are committed to regularly conducting a range of reviews, not only on cases which meet statutory criteria (Working Together to Safeguard Children), but also on other cases which can provide useful insights into the way organisations are working together to safeguard, promote and protect the welfare of children.

Role of the LSCP Quality and Audit Evidence Committee

The Quality and Audit Evidence Committee of Liverpool LSCP ensures that there is a focus on thematic audits alongside multi-agency case file audits. Thematic audits are completed on issues as identified as the LSCP business priority areas.

The multi-agency audit process enables identification of areas of practice that are working well and those that need improvement across the partnership. Learning from the audits will be widely shared. Audits also promote service development through the identification of key practice issues which are addressed in action plans that are implemented and monitored by the LSCP.

Members of Liverpool LSCP are expected to feedback the outcomes and implications of the audit findings within their own agency, ensure that progress is made on any actions which they are responsible for and provide updates to the LSCP.

The process of multi-agency audit enables the LSCP to carry out its function of monitoring the effectiveness of what is done to protect children and monitor their welfare. Audits promote service improvement through the identification of key practice issues so that recommendations can be drawn together and action plans implemented and monitored.

Findings, recommendations and outcomes resulting from multi-agency audit feed into LSCP policy and practice guidance, LSCP training and development activity and strategy and commissioning processes.

7. Additional Learning and Improvement Activities

Any additional Learning and Improvement activity will be informed from a range of other sources including learning from other significant national inquiries and reviews, from national and local research findings and from listening to the voice of local front line practitioners, from children, young people and their families.

The LSCP will also include request from organisations / staff / managers details of cases where Multi Agency working produced improved or good outcomes.

Table 1 details the range learning methodologies utilised by Liverpool LSCP.

Click here to view Appendix 5: Learning and Improvement Framework – Activities.

Other Sources of Learning

Liverpool LSCP elicits learning from a range of sources as outlined below. This includes local findings from the work undertaken by the various LSCP Committees but also utilises information and Learning from National findings:

  • National and Regional Reviews;
  • Audit: Multi Agency & Single Agency;
  • LSCP Performance Management;
  • LSCP Committees;
  • Other (Children / Families / Staff).  

8. Role of the LSCP Committees in the Dissemination of Learning

This framework will apply to Liverpool LSCP and all partner agencies in their delivery of workforce development activities. It should also inform single agency frameworks to ensure connectivity and compatibility. It is also therefore essential that the members of LSCP Professional Development Committee reflect the wide range of both statutory and non-statutory bodies, partner organisations and other key agencies within the Adults, Children and Families workforce.

Membership is made up of those multi - agency professionals who act as key leads for Workforce Development within their agency or who have a role in supporting learning and improvement within their agency. It may also be appropriate to co-opt further members onto this group as appropriate for short fixed periods of time to complete actions required to disseminate local learning following a specific review.

The learning and recommendations identified following review can be implemented in a number of ways, such as improved procedures and policies, supported through training programmes and in other relevant learning activities. In some cases it will be incumbent on individual agencies to consider how these recommendations can best be implemented and in turn provide assurance to the LSCP that this has been achieved effectively.

Members of the Critical Incident Group will be accountable for ensuring that actions for their agency have been completed and for ensuring that identified learning has been effectively disseminated within their agency. This will be completed in conjunction with the LSCP Professional Development Committee.

Completed action plans will be reviewed and the impact measures collated at the scheduled biannual meetings.

Key messages identified at review will also be integrated within LSCP Multi Agency Level 1 and Level 2 Training. Further training needs may also be identified.

Click here to view LSCP Review - Learning and Improvement - Process Flowchart.


Appendix 1: Learning and Improvement Index

Appendix 2: LSCP Critical Incident Group Process - Flowchart

Appendix 3: LSCP Process: Responding to Cases that May Warrant the Undertaking of a Serious Case Review

Appendix 4: LSCP Serious Case Review: Request for CIG Consideration Form (CIGSCR1)

Appendix 5: Learning and Improvement Framework – Activities