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10.1 Serious Case Reviews

SCOPE OF THIS CHAPTER

This chapter details the criteria for initiation of a Serious Case Review (SCR) and the LSCP SCR process, the criteria of an incident which is deemed as being a Notifiable Incident and the requirements under which LSCP publishes its Serious Case Review Reports.

See also Learning and Improvement Framework Safeguarding Children Procedure.

RELATED GUIDANCE

Working Together to Safeguard Children, Chapter 4: Learning and Improvement Framework, Serious Case Reviews.

A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Partnerships to assist with Liaison and Exchange of Information where there are simultaneous Chapter 8 Serious Case Reviews and Criminal Proceedings (CPS, April 2011)

Liverpool LSCP Learning & Improvement Framework (LIF)

Note: these procedures adapted with permission from Sunderland SCB.

AMENDMENT

This chapter was updated in March 2018: Working Together to Safeguard Children says that reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. See Section 5, Appointing Reviewers.


Contents

  1. Serious Case Reviews, Criteria for Undertaking a Serious Case Review and Notifiable Incidents
  2. Decisions Whether to Initiate a Serious Case Review
  3. National Panel of Independent Experts on Serious Case Reviews
  4. Methodology for Learning and Improvement
  5. Appointing Reviewers
  6. Timescale for Serious Case Review Completion
  7. Engagement of Organisations
  8. Agreeing Improvement Action
  9. Publication of Reports
  10. Local Processes: LSCP Critical Incident Group and LSCP SCR Process

    Appendix 1: Responding to Cases that May Warrant the Undertaking of a Serious Case Review

    Appendix 2: LSCP Critical Incident Evidence Committee Process - Flowchart

    Appendix 3: LSCP Serious Case Review: Request for CIEC Consideration Form

    Appendix 4: LSCP Review Learning and Improvement Process Flowchart


1. Serious Case Reviews, Criteria for Undertaking a Serious Case Review and Notifiable Incidents

Working Together to Safeguard Children (p75) details the requirements under which LSCP is required to initiate Serious Case Reviews (SCRs):

Regulation 5 of the Local Safeguarding Children Partnerships Regulations 2006 sets out the functions of LSCPs. This includes the requirement for LSCPs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set 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 - (i) the child has died; or (ii) 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” 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. LSCP will ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCP must commission an SCR.

Thus cases meeting either of these criteria must always trigger a Serious Case Review:

  1. Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
  2. 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.

In addition, even if one of the criteria is not met, an SCR will 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. (Working Together to Safeguard Children).

Notifiable Incidents

A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected;
  • A looked after child has died (including cases where abuse or neglect is not known or suspected); or
  • A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCP or LSCPs promptly, and within five working days of becoming aware that the incident has occurred.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

Contact details and notification forms for notifying incidents to Ofsted are available on Ofsted's website.


2. Decisions Whether to Initiate a Serious Case Review

The LSCP for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Appendix 1: Responding to Cases that May Warrant the Undertaking of a Serious Case Review) for a Serious Case Review. This decision will normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCP. The Chair may seek peer challenge from another LSCP Chair when considering this decision (and also at other stages in the Serious Case Review process).

The LSCP must notify Ofsted and the National Panel of Independent Experts of the decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the LSCP chair may be asked to give evidence in person to the panel.

If the Serious Case Review criteria are not met, the LSCP may still decide to commission a Serious Case Review or an alternative form of case review.


3. National Panel of Independent Experts on Serious Case Reviews

Since 2013 there has been a national panel of independent experts to advise LSCPs about the initiation and publication of SCRs.

The role of the panel is to support LSCPs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel also reports to the Government their views of how the SCR system is working.

The panel's remit includes advising LSCPs about:

  • Application of the SCR criteria;
  • Appointment of reviewers; and
  • Publication of SCR reports.
LSCP have regard to the panel's advice when deciding whether or not to initiate an SCR, when appointing reviewers and when considering publication of SCR reports. LSCP Chairs and LSCP members will comply with requests from the panel as far as possible, including requests for information such as copies of SCR reports and invitations to attend meetings.


4. Methodology for Learning and Improvement

'Working Together to Safeguard Children' does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

See: Liverpool LSCP Learning & Improvement Framework (LIF).

4.1 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.

Serious case Reviews are not limited to systems methodology; there may be cases which require the inclusion of issues from outside a strictly defined systems model.

* Fish, S., E. Munro, and S. Bairstow, Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 2008, Social Care Institute for Excellence: London)
** Undertaking Serious Case Reviews using the Social Care Institute for Excellence (SCIE) Learning Together systems model: lessons from the pilots. March 2013
*** NHS Improvement, Learning from patient safety incidents
**** Protecting Children in Wales. Guidance for Arrangements for Multi-Agency Child Practice Reviews. 2013

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 Safeguarding Children Procedure, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.


5. Appointing Reviewers

The LSCP must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. The lead reviewer will be independent of the LSCP and the organisations involved in the case. The LSCP will provide the national panel of independent experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCP will consider carefully any advice from the independent expert panel about appointment of reviewers.

The LSCP will provide the National Panel of Independent Experts (see Section 2.3, 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.

Working Together to Safeguard Children says that reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.


6. Timescale for Serious Case Review Completion

The LSCP will aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related court proceedings), every effort will be made while the SCR is in progress to:

  1. Capture points from the case about improvements needed; and
  2. Take corrective action to implement improvements and disseminate learning.


7. Engagement of Organisations

The LSCP will ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family. The priority will be to engage organisations in a way which will ensure that important factors in the case can be identified and appropriate action taken to make improvements. The LSCP may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.


8. Agreeing Improvement Action

The LSCP will oversee the process of agreeing with partners what action they need to take in light of the SCR findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.


9. Publication of Reports

All reviews of cases meeting the SCR criteria will result in a report which is published and readily accessible on the LSCP's website for a minimum of 12 months. Thereafter the report will 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 will be taken into consideration. SCR reports will 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 SCR reports will:

  • 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.

LSCP will publish, either as part of the SCR report or in a separate document, information about: actions which have already been taken in response to the review findings; the impact these actions have had on improving services; and what more will be done.

When compiling and preparing to publish reports, LSCP will consider carefully how best to manage the impact of publication on children, family members and others affected by the case. LSCP will comply with the Data Protection Act 2018 in relation to SCRs, including when compiling or publishing the report, and will comply also with any other restrictions on publication of information, such as court orders. The timing of publication will have due regard to the impact on any ongoing legal proceedings, including any inquest.

LSCP will send copies of all SCR reports, including any action taken as a result of the findings of the SCR, to Ofsted, DfE and the national panel of independent experts at least seven working days before publication.

If LSCP considers that an SCR report will not be published, it will inform DfE and the national panel. The national panel will provide advice to the LSCP. The LSCP will provide all relevant information to the panel on request, to inform its deliberations. In cases where an LSCP is challenged by the panel to change its original decision about publication, the LSCP will inform Ofsted, DfE and the national panel of their final decision.


10. Local Processes: LSCP Critical Incident Group and LSCP SCR Process

LSCP Critical Incident Group

The Critical Incident Group (CIG) of LSCP is responsible for undertaking and establishing the need for a Serious Case Review (SCR) or any other review, ensuring that actions, based on recommendations from reviews, are implemented. In addition the Critical Incident Group work with the LSCP Learning and Improvement Sub Group lessons towards ensuring that the lessons are learned and any required changes to practice are implemented.

The Group has responsibility for monitoring the quality of work, commissioned by LSCP, from independent consultants including authors of overview reports and chairs of the review process.

The CIG has responsibility for monitoring implementation of single and multi-agency actions that arise from the findings of serious case reviews or any other review initiated following a serious incident.


Appendices

Appendix 1: Responding to Cases that May Warrant the Undertaking of a Serious Case Review

Appendix 2: LSCP Critical Incident Evidence Committee Process - Flowchart

Appendix 3: LSCP Serious Case Review: Request for CIEC Consideration Form

Appendix 4: LSCP Review Learning and Improvement Process Flowchart

End