Purpose of a serious case review
The purpose of a serious case review is to:
- Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children;
- Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result;
- Improve inter-agency working;
- Better safeguard and promote the welfare of children.
Serious case reviews are not enquiries about how a child died or who is culpable; that is a matter for coroners and criminal courts respectively to determine.
Equally, serious case reviews are not part of any disciplinary process, but may highlight information which may indicate that one or more agencies should consider disciplinary action within established procedures.
Criteria for convening a serious case review
A LSCB should always undertake a serious case review when a child dies (including death by suicide), and abuse or neglect is known or suspected to be a factor in the child's death. Unless there is an exceptional reason, there should always be a Serious Case Review where a child has been killed by a parent with a mental illness. This is irrespective of whether Children's Social Care is or has been involved with the child or family.
The LSCB should also consider a review when there are concerns about the way in which local professionals and services worked together with respect to a child:
- Who sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect; or
- Who has been subjected to particularly serious sexual abuse; or
- Whose parent has been killed in a domestic violence situation; or
- Whose case gives rise to concerns about inter-agency working to protect children from harm.
Where more than one LSCB has knowledge of a child, the LSCB for the area in which the child is / was normally resident should take lead responsibility for conducting any review (the Primary LSCB). Any other LSCBs that have an interest or involvement in the case should be included as partners in jointly planning and undertaking the review.
In the case of looked after children, the local authority which has responsibility for the child should take lead responsibility for conducting the review, again involving other LSCBs with an interest or involvement.
Any professional may refer such a case to the LSCB if it is believed that there are important lessons for inter-agency working to be learned from the case. It would be the LSCB's responsibility to take note of any referral and make a decision as to what if any action is needed.
In addition, the Secretary of State for the Department for Children, Schools and Families (DCSF) has powers to demand an inquiry be held under the Inquiries Act 2005.
The following questions may help in deciding whether or not a case should be the subject of a serious case review. In circumstances other than when a child dies, the answer ‘yes' to several of these questions is likely to indicate that a review could yield useful lessons:
- Was there clear evidence of a risk of significant harm to a child, which was not recognised by organisations or individuals in contact with the child or perpetrator; or not shared with others; or not acted upon appropriately?
- Was the child abused in an institutional setting (e.g. school, nursery, family centre, Young Offender Institution, Secure Training Centre, children's home or armed services training establishment)?
- Did the child die in a custodial (prison, Young Offender Institution or Secure Training Centre) setting?
- Was the child abused while being looked after by the local authority?
- Did the child commit suicide or die while absent having run away from home?
- Does one or more agency or professional consider that its concerns were not taken sufficiently seriously, or acted upon appropriately, by another?
- Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding children procedures, which go beyond the handling of this case?
- Was the child subject of a child protection plan or had it been previously the subject of a plan or on the child protection register?
- Does the case appear to have implications for a range of agencies and/or professionals?
- Does the case suggest that the LSCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately disseminated, understood or acted upon?
Action to be taken when a child dies or is seriously injured
Any agency or professional may refer a case to the LSCB (after appropriate consultation with his/her line manager or designated or named professional) where it is believed the criteria for a Serious Case Review are met. Notification should be made immediately to the LSCB Manager, who will inform the Chairperson of the LSCB.
In some cases, where the criteria are clearly made out, the LSCB Chairperson will decide immediately that a Serious Case Review should be conducted. In other cases, the Chairperson will ask the Serious Case Review Panel for a recommendation before his or her final decision in made.
In all cases the LSCB Manager will liaise with relevant agencies and a report of the findings will then be presented to the LSCB Chairperson as soon as practicable and within a maximum of 10 working days of the initial notification of the child's death or serious injury.
The LSCB Chairperson will ensure that within one month of notification, a meeting of the Serious Review Panel is convened to decide whether a Serious Case Review is to be undertaken.
Where the criteria appears to be met, the LSCB Manager will then ensure that these procedures are followed within the timescales laid down.
Securing the files
Once it is known that a case is being considered for review, The LSCB Manager will ask each relevant organisation to secure both paper and electronic relating to the case to guard against loss or interference.
Where the decision is later taken not to hold a Serious Case Review, the LSCB Manager will inform all relevant organisations to rescind the instruction to secure all relevant files and documentation.
The Serious Case Review Panel
The LSCB Chairperson should convene a serious case review panel within one month of notification. The LSCB Manager will write to all relevant organisations asking them to provide a short written report to the panel giving the known outline of the case. These reports will be used to inform the panel as to whether the criteria are met to hold a serious case review. The LSCB Chairperson is to be sufficiently informed about the circumstances and the recommendations arising from the meeting.
The review panel can make the following recommendations to the LSCB Chairperson:
- To convene an Overview Panel to undertake a Serious Case Review;
- To defer a decision until more information is available (e.g., Coroners Report);
- To require agencies to undertake internal management reviews;
- To undertake a smaller-scale audit of cases which do not meet the criteria of Serious Case Review;
- To undertake a non statutory review with an Independent Chairperson.
The decision should be forwarded as a recommendation to the LSCB Chairperson within five working days within of the panel meeting.
The LSCB Chairperson has ultimate responsibility for deciding whether or not to conduct a serious case review. Where there is disagreement between the Panel recommendation and the Chairperson of the LSCB, the case must be brought to the Executive Board of the LSCB.
If the decision is made for a Serious Case Review to be undertaken, no member agency should comment publicly upon the case without prior consultation with the Chairperson of the LSCB.
Where the decision is to hold a Serious Case Review, The LSCB Manager will write to request the Chief Executives or equivalent of the relevant agencies to commence an Internal Management Review. This should be done within two working days of the LSCB Chairperson's decision to hold the review.
The Designated Nurse for Child Protection will inform the relevant Strategic Health Authority of every case that becomes the subject of a Serious Case Review.
Notification to the Department for Children, Schools and Families
The LSCB Chairperson is responsible for ensuring that immediately following this meeting, there is formal notification to the DCSF that a Serious Case Review is to be undertaken.
Determining the scope of the review and Terms of Reference
The Serious Case Review Panel should consider the scope of the review process for the individual case and draw up clear terms of reference. Relevant issues include:
- What appear to be the most important issues to address in trying to learn from this specific case? How can the relevant information best be obtained and analysed?
- Who should be appointed as the independent author for the overview report?
- Who should be appointed as Independent Chair?
- What time period should be reviewed (i.e. how far back should enquiries cover), and what is the cut off point?
- What family history / background information will help to better understand the recent past and present?
- Whether agencies or professionals other than LSCB members automatically asked to conduct a management review should be asked to submit a report or otherwise contribute and how this is to be achieved (specialist tertiary hospital trusts may be involved in serious case reviews because of the nature of the services they offer);
- Whether there is a need to involve agencies / professionals from other LSCB areas and how this is best achieved;
- Whether and how to involve family members in the review and what information will be made available to them.
- The agreed timescales for completion of the review;
- Whether there is a need to bring in an outside expert at any stage to shed light on crucial aspects;
- Whether the case will give rise to other parallel investigations of practice (e.g. independent health investigation, homicide review);
- How should the review process take account of a coroner's inquiry and (if relevant) any criminal investigations or proceedings related to the case? How best to liaise with the coroner and/or the Crown Prosecution Service?
- How should any public, family and media interest be managed, before, during and after the review?
- Does the LSCB need to obtain independent legal advice about any aspect of the proposed review?
Some of these issues may need to be re-visited as the review progresses and new information emerges.
Chairperson and Individual SCR Panel
The Independent Chairperson will convene meetings of the Individual Serious Case Review Panel with the Overview Report Writer. The Chairperson's responsibility will be to provide and agenda for the meeting, contact the LSCB Manager if reports are not presented in a timely fashion, inform the Chairperson of the LSCB if the timescales are not going to be met and work with the Overview Report Writer to resolve any outstanding i ssues. The first meeting will look at resolving any issues around remit. Subsequent meetings will look at the Multi Agency Chronology and IMRs.
The individual SCR Panel will consist of those members of the standing SCR group that are not involved in any way with the case or are providing an IMR for their agency.
Timescales
The LSCB Chairperson should make the decision on whether to hold a review within one month of a case coming to their attention. The lessons from serious case reviews should be learned and acted upon as quickly as possible.
The individual management reviews must be conducted and the reports submitted to the panel Chairperson within three months (unless otherwise agreed) of the LSCB Chairperson's decision to initiate the review.
The serious case review should be completed within six months of the LSCB Chairperson's decision to initiate the review, unless an alternative timescale is agreed with Government Office, Yorkshire and Humberside. Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it emerges that a review cannot be completed within six months of the LSCB Chairperson's decision to initiate it, there should be a discussion with Ofsted to agree a timescale for completion.
In some cases, criminal proceedings may follow the death or serious injury of a child. Those co-ordinating the review should discuss with the relevant criminal justice agencies at an early stage how the review process should take account of such proceedings, their potential impact on criminal investigations and who should contribute at what stage.
Serious case reviews should not be routinely delayed because of outstanding criminal proceedings or an outstanding decision on whether or not to prosecute. In some cases it may not be possible to complete or to publish a review until after the coroner's investigation or criminal proceedings have been concluded. However, this should not prevent early lessons learned from being implemented.
- Confirm that arrangements have been made (where necessary via a strategy meeting) to ensure the safety of other children or family members;
- Check the ICS/ Contact Point data bases to establish if the adult/s or child/ren are known;
- Check with the police and designated doctor and nurse for any relevant information;
- Secure the Children's Social Care files;
- Inform the Director of Children's Services;
- Identify the agencies which have been involved with the child and alert them, via a letter from LSCB Chairperson to their chief executive, to their obligation to undertake an internal management review as a contribution to the overall serious case review;
- Inform Government Office and Ofsted.
The early alert to relevant agencies should cover the need for nominated / designated child protection professionals to:
- Liaise with the case accountable children's social worker before making contact with the family;
- Secure files;
- Collate relevant procedures;
- Make arrangements for adequate support for the professionals involved.
Within two further working days, the LSCB Manager should:
- Complete a briefing report for the Director of Children's Services, the LSCB and the case review panel;
- Submit the required report form to Ofsted following agreement with the Chairperson of the LSCB.
Serious Case Review Timescale Guide
Date |
Key Actions |
Additional Actions |
Day 0 |
|
Case referred by agency to LSCB Chairperson for consideration of SCR. |
1 week |
LSCB Chairperson refers to SCR Sub Group. |
LSCB Manager sets up meeting and prepares report for LSCB Chairperson of early information. |
End week 4 |
|
SCR Sub Group makes recommendation, determines agency involvement and scope of review, recommends who will Chair the Overview Panel and agrees password. |
End week 5 |
LSCB Chairperson informs all agencies |
Copy to N.Yorks Communications Unit - and CPS and Coroner where criminal proceedings or death. |
End week 6 |
The LSCB Manager arranges a series |
A briefing meeting will be held for Investigating Managers convened by the LSCB Manager. |
End week 9 |
All agency chronologies should have |
LSCB Administrator prepares merged chronology. |
End week 11 |
All Individual Management Reviews |
The Senior Designated Manager signs off the Individual Management Report on behalf of their agency. |
End week 14 |
Overview Report Writer completes the |
1st draft of Overview Report is discussed with the Overview Panel. |
End week 16 |
Overview Report Writer and Action |
Final Overview Report and Action Plans discussed with Overview Panel. |
Week 17 |
Overview Report and Action Plans discussed with the Chair of the LSCB |
|
End week 20 |
LSCB Chairperson takes draft Overview Report Executive Summary and Action |
Special LSCB meeting called if necessary. |
End week 22 |
Final report sent by Overview Panel Chairperson to LSCB Chairperson and circulated to Executive Members. |
Executive Summary shared with the family, usually by the same person as informed them of the review (see week 5) |
End week 24 |
|
Training Unit plan briefing sessions of lessons learnt throughout the county. |
End week 40 |
LSCB SCR Sub Group checks progress |
Positive outcomes for children and families and for multi-agency staff resulting from the actions taken in response to the SCR are recorded. |
LSCB Chairperson signs off SCR
Individual Management Reviews (IMR)
Once a serious case review has been agreed relevant agencies must identify an Individual Management Report writer. The report writer must not have/had any operational responsibility for the child or children. They must be of sufficient seniority to command respect and resources within their organisation. Those considered suitable would be, for example, General Managers, Police Inspectors, Named Nurses etc.
The aim of management reviews should be to:
- Establish a factual chronology of the action which has been taken within the agency;
- Analyse the involvement of the agency;
- Consider what lessons may be learned from the case about the way in which the agency works to safeguard children and promote their welfare;
- Recommend appropriate action in the light of the review's findings; this should include the intended outcomes and an expectation that the agency will review whether these have been achieved.
The findings from the management review reports should be accepted by the senior officer in the organisation who has commissioned the report and who will be responsible for ensuring that recommendations are acted upon.
Managers within agencies will ensure that all necessary assistance is given to IMR writers. To facilitate this, each LSCB agency should have clear procedures on the conduct of management reviews.
The police may be restricted in the amount of information they can provide for the serious case review during the process of criminal investigation. Information collected by the police may be subject to rules of disclosure for court proceedings.
Feedback
It is recognised that the process could incur stress on individual workers and that, at any stage, issues may be identified which require consideration through disciplinary or similar processes. The LSCB Manager will organise briefing sessions for all staff once the Ofsted Evaluation letter has been received. However individual staff should be debriefed by the IMR writer as and when agreed by the Chairperson of the individual Serious Case Review Panel. This will be before the universal sessions and may (depending on the nature of the incident) be before the Overview and Executive Summary are presented to the Executive Board of the LSCB. This does not override any consideration through disciplinary or similar processes. Likewise action may need to be taken immediately by agencies to secure the safety of children within their responsibilities.
Where a child dies in a custodial setting (prison, Young Offender Institution or Secure Training Centre) the Prisons and Probation Ombudsman should investigate and report on the circumstances surrounding the death of the child. The investigation should examine the child's period in custody, including an assessment of the clinical care they received. The report should be made available to assist any serious case review process.
Individual Management Review briefing
The LSCB Manager will convene a briefing for IMR Report writers before they start their reports. The aim of the briefing is to:
- Consider the scope of the review, timescales and the agreed terms of reference;
- Identify appropriate IMR report writers;
- Consider gaps in information and ensure all appropriate agencies are involved;
- Ensure writers have access to the electronic chronology tool and understand the abbreviations that will be used;
- Share a prepared genogram;
- Share an agreed format for the review;
- Ensure writers are clear about briefing and feedback processes for staff within their agency
- Meet the independent chairperson and overview report writer.
Individual Management Review format
The following outline format should guide the preparation of management reviews, to help ensure that the relevant questions are addressed, and to provide information to LSCBs in a consistent format to help with preparing an overview report. The questions posed do not comprise a comprehensive checklist relevant to all situations. Each case may give rise to specific questions or issues which need to be explored and the serious case review subcommittee should consider carefully the circumstances of individual cases and how best to structure the review in the light of those particular circumstances.
Where staff or others are interviewed by those preparing management reviews, a written record of such interviews should be made and this should be shared with the relevant interviewee. Interviewees should be given a copy of the LSCB Leaflet: Serious Case Reviews - A Guide for Professionals.
What was our involvement with this child and family?
Construct a comprehensive chronology of involvement by the organisation 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.
- Refer to family members and professionals using agreed anachronisms. Identities should not be divulged beyond the case review panel;
- Give references for original material;
- Briefly summarise decisions reached, the services offered and/or provided to the child/ren and family, and other action taken.
Analysis of involvement
In analysing the involvement with the child and/or family, the following areas should be specifically considered:
- Were practitioners sensitive to the needs of children in their work, knowledgeable about potential indicators of abuse and neglect and what to do if they had concerns about a child?
- Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?
- Were these policies and procedures used in this case?
- 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 actions accord with assessments and decisions made? Were appropriate services offered / provided or relevant enquiries made in the light of assessments?
- Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?
- When and in what way were the children's wishes and feelings ascertained and taken account of when making revisions about children's services? Was this information recorded?
- Was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?
- Were more senior managers or other organisations and professionals involved at points when they should have been?
- Was work on this case consistent with each organisation's and the LSCB's policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?
- Were there sufficient resources to allow professionals to undertake their role?
What do we learn from this case?
When analysing potential learning from the case, the following questions should be considered:
- Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children?
- 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 organisations; resources?
Recommendations for action
When making recommendations for action, the following questions should be considered:
- What action should be taken, by whom and by when?
- What outcomes should these actions bring about, and how will the organisation evaluate whether they have been achieved?
- The findings should be accepted by the agency's chief executive or equivalent, who is responsible for ensuring that recommendations are acted upon.
Example: Individual Management Review (IMR) Report Format
Agency (and logo)
Serious Case Review: Name of subject
Case details: This is a brief overview of the case*.
Family members:*
Genogram:*
About the author: a paragraph outlining role, experience and independence from the case.
Nature if the incident/circumstances leading to the decision to hold a Serious Case Review
Terms of Reference:*
Scope of the IMR: to include family involvement (if none, explain steps taken to obtain this), ethnicity, race, disability, gender issues.
Summary of Single Agency Chronology: A factual account of what happened – the story from the agency perspective.
Analysis of Key Issues: these are important practice issues arising from the summary above.
Lessons learned: It is appropriate in many cases to present lessons in a thematic way.
Recommendations: Should clearly be linked to the lessons learned (and lead directly into the Agency Action Plan once the report is agreed by the agency). All recommendation s should be SMART.
Prepared by: Name/ Job Title
Signed
Agreed by: Name/ Job Title
Signed
* Indicates material provided by the LSCB SCR Panel
The LSCB overview report
The serious case review panel chaired by the independent person is responsible for producing a composite overview report for the LSCB which brings together the facts, analyses the findings of the internal management and other reports and makes recommendations for future action.
The overview report should be commissioned from a person who is independent of all the agencies / professionals involved.
The LSCB overview report should bring together and draw overall conclusions from the information and analysis contained in the individual management reviews and information from the child death review processes, together with reports commissioned from any other relevant interests. Overview reports should be produced according to the following outline format although, as with management reviews, the precise format will depend upon the features of the case. This outline will be most relevant to abuse or neglect which has taken place in a family setting.
Suggested format for LSCB overview reports
Introduction: |
|
The facts: |
|
Analysis: |
This part of the overview should look at how and why events occurred, decisions were made, actions taken or not. This is the part of the report in which 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 any examples of good practice should be highlighted. |
Conclusions and recommendations: |
This part of the report should summarise what, in the opinion of the review panel, are the lessons to be drawn from the case, and how those lessons should be translated into recommendations for action. Recommendations should include, but should not simply be limited to, the recommendations made in individual reports from each organisation. Recommendations should be few in number, focused and specific, and capable of being implemented. If there are lessons for national as well as local policy and practice, these should also be highlighted. |
Overview reports
Overview reports may require authors to seek additional information, conduct interviews with staff and request additional work from individual management review contributors. Overall the key features of a good overview report include:
- Well set out with clear headings and sections;
- Detailed combined chronology which includes when the child was seen;
- A genogram, and flow chart with the child's moves, where appropriate;
- A summary of family history;
- Whether any staff or family members were interviewed as part of the process;
- Whether issues of race, culture, language, religion and disability were covered and addressed;
- The wishes and feelings of the family and the child, where appropriate;
- Information from previous serious case reviews, enquiries, research ato inform conclusions;
- An analysis of actions and interventions, focusing on what went wrong and why, and whether different actions would have led to different conclusions;
- A critical appraisal of the individual management reviews and their contributions to learning the lessons;
- The lessons to be learned set clearly, providing valuable learning for all professionals;
- A coordinated set of specific and well structured recommendations, such as;
- An action plan setting out targets, outcomes, responsibilities and how practice is expected to change as a result;
- A monitoring and evaluation process that involves individual agencies and the LSCB as a whole;
- Overall conclusions and whether they have wider implications for national policy and practice.
Process of compiling the LSCB overview report
Each agency will provide the LSCB Administrator with their single agency chronology. This will be merged into a multi-agency chronology, which will form a part of the LSCB overview report. If there is a problem in receiving reports etc in a timely manner this will be brought to the attention of the LSCB Chairperson and the chairperson of the serious case review sub group in order that issues can be followed up speedily.
The Chairperson, the overview report writer and the individual serious case review panel will at the first meeting;
- Consider the remit, and outstanding issues and who will contact the family.
At a subsequent meeting they will consider;
- The multi agency chronology
- The agency IMR reports. Each agency involved will determine what further action is required within their own agency. This will be included in their own agency review report and shared with the serious case review panel.
- Identify the key issues against the format for the overview report.
A further meeting is convened of the serious case review panel to consider the draft overview report prior to the Executive Board of the LSCB.
On receiving an overview report, the Executive Board of the LSCB should:
- Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report;
- Translate recommendations into an action plan which should be signed up to at a senior level by each of the organisations that need to be involved. The plan should set out who will do what, by when, and with what intended outcome. The plan should set out 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 the report or key findings to interested parties as agreed. Make arrangements to provide feedback and de-briefing to staff, family members of the subject child and the media, as appropriate;
- Agree the Executive Summary in accordance with the NAP;
- Agree any urgent action arising from the serious case review which requires immediate action;
- Provide a copy of the overview report, action plan and individual management reports to Ofsted and the Department for Children Schools and Families (DCSF).
Executive Summary
There should be a suitable anonymised Executive Summary, provided by the independent professional, which will be made public and which will include as a minimum, information about the review process, key issues arising from the case and the recommendations which have been made. The publication of the Executive Summary will need to be times in accordance with any related Court proceedings.
The Overview Report and Executive Summary should be agreed at a meeting of the Serious Case Review Panel.
LSCB Responsibility
On receiving the Overview Report and Executive Summary the Executive Board of the LSCB should:
- Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the Overview Report;
- Translate recommendations into an Action Plan and agree a process for implementing, reviewing and auditing actions;
- Clarify to whom the report, or any part of it, should be made available;
- Make arrangements to provide feedback and de-briefing to staff, family members and media as appropriate;
- Agree a strategy for disseminating key findings and recommendations;
- Provide a copy of the Overview Report, Executive Summary, Action Plan and individual Single Agency Management Review Reports to the DCSF and, Strategic Health Authority;
- Ensure that the Executive Summary is used for any communication with the media or public.
Disciplinary Enquiries/Action
Serious Case Reviews may be conducted concurrently with disciplinary enquiries or action. The process however, must remain separate.
Decision not to Proceed with a Serious Case Review: Learning Lessons Reviews
If the Serious Case Review Panel decides the criteria for a Serious Case Review is not met, a decision should be made about the appropriateness of conducting a review to look at whether lessons can be learned. This may involve one or more agencies and is known in North Yorkshire as a Learning Lessons Review.
As far as possible, the same standards and ways of working as described above should be followed. The Action Plan and Executive Summary should be agreed as above. Ofsted can ask to see any review undertaken by either the LSCB or one of its constituent agencies. Further it can use a Learning Lessons Review to inform both its judgements on an unannounced or announced inspection.
In such cases the relevant findings should be made available to the Serious Case Review Panel within six months.
Audit and monitoring
Monitoring of the action plan produced from the overview report will be undertaken by the serious case review sub group reporting back to Executive Board of the LSCB.
Any areas of inter-agency activity identified as of particular concern should be referred for consideration by the performance sub group as a potential area for future audit and research.
Reviewing institutional abuse
When serious abuse takes place in an institution, or multiple abusers are involved, the same principles of review apply but reviews are likely to be more complex, on a larger scale, and may require more time. Terms of reference need to be carefully constructed to explore the issues relevant to the specific case.
For example, if children had been abused in a residential school, it would be important to explore whether and how the school had taken steps to create a safe environment for children, and to respond to specific concerns raised.
There needs to be clarity over the interface between the different processes of investigation (including criminal investigations); case-management, including help for abused children and immediate measures to ensure that other children are safe; and review (i.e. learning lessons from the case to reduce the chance of such events happening again). The three different processes should inform each other. Any proposals for review should be agreed with those leading criminal investigations, to make sure that they do not prejudice possible criminal proceedings.
Scrutiny of the SCR by Ofsted
The overview report with the individual management reviews will be sent to Ofsted for scrutiny. The findings of any review can not be made public until the Ofsted Evaluation.
Accountability and disclosure
The Executive Board of the LSCB will consider carefully who might have an interest in reviews – for example, elected and appointed members of authorities, staff, members of the child's family, the public, the media, and what information should be made available to each of these groups. There are difficult interests to balance, among them:
- The need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others;
- The accountability of public services and the importance of maintaining public confidence in the process of internal review;
- The need to secure full and open participation from the different agencies and professionals involved;
- The responsibility to provide relevant information to those with a legitimate interest;
- Constraints on public information sharing when criminal proceedings are outstanding, in that providing access to information may not be within the control of the LSCB.
Where the LSCB agrees that all or part of the Overview Report may be read by an interested party who is not an LSCB member, it is the expectation this will take place by arrangement at the LSCB Office. Exceptionally and only with the consent of the LSCB Chairperson, should copies be made of all or part of the overview report.
It is important to anticipate requests for information and plan in advance how they should be met. For example, a lead agency may take responsibility for de-briefing family members, or for responding to media interest about a case, in liaison with contributing agencies and professionals.
However the LSCB is no longer considered a public body with regards to the Freedom of Information Act. Therefore it is the responsibility of the Chairperson of the LSCB to recommend what should be placed in a public domain other then the Executive Summary.
In all cases, the LSCB overview report should contain an executive summary which will be made public, which includes as minimum information about the review process, key issues arising from the case and the recommendations which have been made. The publication of the executive summary will need to be timed in accordance with the conclusion of any related court proceedings. The content will need to be suitably anonymised in order to protect the confidentiality of relevant family members and others.
The LSCB will ensure that the strategic health authority (SHA) is briefed, so that they can work jointly to ensure that the Department of Health and the DCSF respectively are fully briefed in advance about the publication of the executive summary.
Learning lessons locally
Reviews are of little value unless lessons are learned from them. At least as much effort should be spent on acting upon recommendations as on conducting the review. The following may help in getting maximum benefit from the review process:
- As far as possible, conduct the review in such a way that the process is a learning exercise in itself, rather than a trial or ordeal;
- Consider what information needs to be disseminated, how, and to whom, in the light of a review. Be prepared to communicate both examples of good practice and areas where change is required;
- Focus recommendations on a small number of key areas, with specific and achievable proposals for change and intended outcomes; primary care trusts (PCTs) should seek feedback from the strategic health authority, who should use it to inform their performance management role;
- The LSCB should put in place a means of auditing action against recommendations and intended outcomes;
- Seek feedback on review reports from Ofsted, who should use reports to inform inspections and performance management.
Day-to-day good practice can help ensure that reviews are conducted successfully and in a way most likely to maximise learning:
- Establish a culture of audit and review. Make sure that tragedies are not the only reason inter-agency work is reviewed;
- Have in place clear, systematic case recording and record keeping systems;
- Develop good communication and mutual understanding between different disciplines and different LSCB members;
- Communicate with the local community and media to raise awareness of the positive and ‘helping' work of statutory services with children, so that attention is not focused disproportionately on tragedies;
- Make sure staff and their representatives understand what can be expected in the event of a child death / case review.
Learning lessons regionally and nationally
Taken together, child death and serious case reviews should be an important source of information to inform national policy and practice.
The DCSF is responsible for identifying and disseminating common themes and trends across review reports, and acting on lessons for policy and practice. The DCSF will commission overview reports at least every two years, drawing out key findings of serious case reviews and their implications for policy and practice. It is considering how best to disseminate the findings from the work of the local child death overview teams.
Professionals may also wish to refer to working Together to Safeguard Children (DfES, 2006) chapter 8, which contains additional information and may assist.
Serious Incidents
All Serious Incidents must be reported to the LSCB Safeguarding Unit. These incidents include;
- Cases bought to the attention of Ofsted and the Government Office because of concern about professional practice or implications for Government policy;
- Cases which raise issues about a council's professional practice that may need to be considered further in the context of performance assessment
- Cases that have attracted or are likely to attract media attention.
The definition of a serious incident includes;
- Death of a child accommodated in the home, residential family centre, placed with foster parents or receiving support from an adoption support agency.
- Referral to the Secretary of State pursuant to Section 2(1)(a) of the Protection of Children Act 1999(a) of an individual working at the home, or working for the fostering service.
- Serious illness or serious accident sustained by a child accommodated in a children's home, residential family centre, placed with foster parents or receiving support from an adoption support agency.
- Involvement or suspected involvement of a child accommodated at a children's home, residential family centre or placed with foster parents, in prostitution.
- Serious incident that requires police to be called to the home.
- Allegation that a child has committed a serious offence.
- Any serious complaint about the home or persons working there, or serious complaint about any foster parent approved by the fostering agency.
- Instigation and outcome of any child protection enquiry involving a child accommodated at the home or a child placed with foster parents.
The LSCB Manager will assess each incident against the criteria and will if necessary report the incident to Ofsted. Before reporting can take place the LSCB Manager will contact the reporting officer for all available information in order to complete the Ofsted Serious Incident Form.
Within one month of reporting the incident the LSCB Manager will complete a report for Ofsted detailing any action taken or any further action to be taken including an SCR or non statutory review.
All Serious Incidents will be reviewed by the SCR Panel including those that do not meet the SCR Criteria. A data base of incidents is held by the LSCB Safeguarding Unit to allow the LSCB Performance Sub Group to monitor and evaluate trends or lessons learned.
Serious Incidents that take place in residential units will be reported by the Manager for the Residential Services and will not be covered by these procedures.
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