10.0 Serious Case Reviews
- 10.01 Introduction
- 10.02 Instigating a Case Review
- 10.03 The Scope of the Review
- 10.04 Timing
- 10.05 Process
- 10.06 Review by Management - Advice on Scope and Terms of Reference
- 10.07 The Safeguarding Children Board Overview Report
- 10.08 Reviewing Institutional Abuse
- 10.09 Accountability and Disclosure
- 10.10 System for Evaluation Plan
10.01 Introduction
10.1 The North Yorkshire Safeguarding Children Board will always carry out a Case Review when a child dies (including death by suicide) and abuse or neglect are known or suspected to be a factor in the death. Local agencies will consider immediately whether there are other children at risk of harm who need safeguarding such as siblings or other children in an institution where abuse is alleged.
10.1.1 Following the Case Review, agencies will consider if there are lessons to be learnt from the tragedy about the way they work together, and if improvements can be made to each agency’s practice.
10.1.2 The Safeguarding Children Board will always consider whether a Review should be conducted where:-
- A child sustains a potentially life threatening injury or serious and permanent impairment of health and development through abuse or neglect, or
- Have been subjected to particularly serious sexual abuse, or
- A parent has been murdered and a homicide review is being initiated
- A child has been killed by a parent with a mental illness
- And the case gives rise to concerns about inter-agency working to protect children.
10.1.3 The purpose of the Case Review is to:-
- Establish whether there are lessons to be learnt from the case about the way in which local professionals and agencies work together to safeguard children
- Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and, as a consequence
- Improve inter-agency working and better safeguard of children.
10.1.4 Case Reviews are not enquiries into how a child died or who was responsible; that is a matter for Coroners and Criminal Courts to determine.
10.1.5 The Safeguarding Children Board for the area in which the child is/was normally resident will take the lead responsibility for conducting the review. Any other Safeguarding Children Board may be involved if they have an interest or involvement in the case.
10.02 Instigating a Case Review
10.2.1 The Board will decide whether or not the case should be the subject of a Case Review by applying the criteria within “Working Together to Safeguarding Children” (2006)
10.2.2 If the criteria are not met, it may be that a decision to carry out individual management reviews or small scale audits may be appropriate. Findings from these would be accountable to the Serious Case Review subgroup.
10.2.3 The Chair of the Safeguarding Children Board will inform the Commission for Social Care Inspection of every case that becomes the subject of a Case Review. The Chair will complete the CSCI “Notification of Critical Child Care Incidents”.
10.3.1 The Safeguarding Children Manager will convene a Serious Case Review Panel on an inter-agency basis, which is responsible for considering the early information available about a case which may warrant a full Case Review. The Panel will recommend to the Chair of the Board whether or not a full Case Review is required. The Serious Case Review Panel will also consider the scope of any review that is recommended.
10.3.2 Terms of reference will be defined which may include a range of items, e.g the time period of events to be reviewed, involvement of family members, review processes to take account of the Coroner’s enquiry, legal advice, and media issues.
10.4.1 Within one month of a case coming to the attention of the Chair of the Safeguarding Children Board, there should be a discussion to advise on whether a Case Review should take place and to draw up the terms of reference. Individual agencies should secure records promptly and begin work on a chronology of that agency’s involvement with the family. Case Reviews will be completed within a further four months unless an alternative timescale is agreed with the Commission for Social Care Inspection at the start of the process.
In cases where criminal proceedings follow the death of serious injury of a child, the review process should take account of such proceedings. In some cases, it may not be possible to complete or to publish until after Coroner’s or criminal proceedings have been concluded but early lessons learnt from the Case Review can be implemented.
10.05 Process
10.5.1 Once a decision is taken, the Safeguarding Children Board Manager will write to the agencies’ representative of the Board (and others who may be involved) giving details of the Case Review and the Terms of Reference.
10.5.2 The Chief Officer from each agency should ensure all files are secured and that a senior manager is appointed to carry out the Review. The manager responsible for the Review should not be directly concerned with the child or family or be the immediate line manager of the staff involved.
10.5.3 The senior manager who carries out the Case Review will need to:-
- Interview key professionals involved in the case of the child and family
- Review all files and other paperwork relating to the case
- Compile a chronological record of involvement with the child and family. The information will come from the written records and from staff interviews. Only information, which is deemed relevant to the care of the child or the conduct of carers, will be included in the Case Review.
- Ensure that a Review is available to the author of the Overview Report within two months of it being requested.
10.5.4 The Board will have identified the author of the Overview Report who will bring together all of the separate agency’s management reports in an Overview Report that will make recommendations for future action.
10.5.5 On completion of the Review report, there will be a process for feedback and debriefing for the staff who are involved, in advance of the completion of the Overview Report by the Board. This may be followed up by a follow up feedback session is the Overview Report raises new issues for the agency and staff members.
10.06 Review by Management - Advice on Scope and Terms of Reference
What was our involvement with this child and family?
Construct a comprehensive chronology of involvement by the agency and/or professional(s) in contact with the child and family over the period of time set out in the Review’s Terms of Reference. Briefly summarise decisions reached, the services offered and/or provided to the child(ren) and family, and other action taken.
Analysis of Involvement
Consider the events that occurred, the decisions made and what actions were or were not taken. Where judgements were made or actions taken that indicate that practice or management could be improved, try and e.g. an understanding not only of what happened, but why. Consider specifically:-
- Were practitioners sensitive to the needs of the child in their work, knowledgeable about potential indicators of abuse or neglect, and about what to do if they had concerns about a child?
- Did the agency have in place policies and procedures for safeguarding children, and were these acted upon?
- What were the key relevant points/opportunities for assessment and decision-making in this case in relation to the child and family?
- Do assessments and decisions appear to have been reached in an informed and professional way?
- Did action accord with assessments and decisions made?
- Were appropriate services offered/provided, or relevant enquiries made, in the light of the assessments?
- Where relevant, were the appropriate child protection or care plans in place, and child protection and/or looked after reviewing process complied with?
- When, and in what way, were the child(ren)’s wishes and feelings ascertained and considered?
- Was this information considered?
- Was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?
- Were more senior managers or other agencies and professionals involved at points where they should have been?
- Was the work in this case consistent with agency and Safeguarding Children Board policy and procedures for safeguarding children, and wider professional standard?
- What do we learn from this case?
- Are there lessons from this case for the way in which this agency works to safeguard children and promote their welfare?
- Is there good practice to highlight, as well as ways in which practice can be improved? Are there implications for ways of working; training (single and inter-agency); management and supervision, working in partnership with other agencies, resources?
Recommendations for Action
What action should be taken, by whom and by when? What outcomes should these actions bring about, and how will the agency review whether they have been achieved?
10.07 The Safeguarding Children Board Overview Report
10.7.1 The following outline format will be used for overview reports. This outline is particularly useful in cases of abuse and neglect in a family setting:
10.7.2 Overview report
Introduction
Summarise the circumstances that led to a review being undertaken in this case.
State the terms of reference of the review
List contributors to the review and the nature of their contributions. List review panel members and author of the overview report.
The Facts
Prepare a genogram showing membership of the family, extended family and household.
Compile an integrated chronology of involvement with the child and family on the part of all relevant agencies, professionals and others who have contributed to the review process. Note specifically in the chronology each occasion on which the child was seen and the child’s views and wishes sought or expressed.
Prepare an overview which summarises what relevant information was known to the agencies and professionals involved about the parents/carers/any perpetrator, and the home circumstances of the children; include ethnicity and cultural issues pertaining to the family.
Analysis
This part of the overview should look at how and why events occurred, decisions were made, actions taken or not. This is part of the report that reviewers can consider, with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events. The analysis section is also where examples of good practice should be highlighted.
The Recommendations
This part of the report should summarise what, in the opinion of the Case Review Subgroup, are the lessons to be drawn from the case and how those lessons should be translated into recommendations for action. Recommendations should include, but not be limited to, the recommendations made in individual agency reports. Recommendations should be few in number, focused, specific and capable of being implemented. If there are lessons for national, as well as local, policy and practice, these should be highlighted.
10.7.3 The report of the Serious Case Review Subgroup will be presented to the Board.
10.7.4 On receiving the overview report, the Board will:-
- Ensure that contributing agencies and individuals are satisfied that their information is fully and fairly represented in the overview report.
- Translate recommendations into an action plan which will be endorsed and accepted at a senior level by each of the agencies. The plan will set out who will do what, by when and with what intended outcome. The plan will specifically identify by what means improvements in practice/systems will be monitored and reviewed.
- Clarify to whom the report, or any part of it, should be made available
- Disseminate report or key findings to interests as agreed. Arrangements will be made to forward a copy immediately to the appropriate members of staff supervising the worker or workers involved with the family. This will be a part of a specific feedback debriefing session as required
- Plan feedback to family members of the subject child and the media, as appropriate
- Provide a copy of the overview report, executive summary action plan and individual management reports to the DfES and CSCI.
10.08 Reviewing Institutional Abuse
10.8.1 When serious abuse takes place in an institution, or multiple abusers are involved, the same principles of review are applicable. Due to the increased complexity of such cases, particular attention needs to be given to the Terms of Reference and the interface between the different processes of investigation (including criminal investigation), case management, help for abused children and immediate measures to safeguard children.
10.09 Accountability and Disclosure
10.9.1 The Board will consider those who may have an interest in the review and what information should be available. To inform this decision, confidentiality in respect of personal information should be considered. In addition, the accountability of public services and the need to maintain public confidence in the process is a significant influence in any decision on the release of information.
10.9.2 The Executive Summary, which is contained within the Safeguarding Children Board Overview Report, will be made public. This will contain, as a minimum, information about the review process, key issues and recommendations. Relevant family members will be anonomised in the Executive Summary. The release of the Executive Summary will take account of any related court procedures.
10.10 System for Evaluation Plans
10.10.1 The primary responsibility for monitoring and evaluating progress on Action Plans lies with senior managers in individual agencies and should be built into their performance management arrangements.
10.10.2 The Serious Case Review Subgroup is responsible for monitoring compliance and it should require all agencies to report to it as required. It should produce an annual report to Board on progress on all outstanding Action Plans. This should include a section on changes in policies and practice as a result of action taken and evidence of the application of learning from Reviews. It should report to Board immediately (or at the next planned meeting) any significant issues arising from progress on Action Plans, especially any failures to make progress or delays in making progress.
