The purpose of a serious case review is to:
- Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;
- Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
- Improve intra and inter-agency working;
- Better safeguard and promote the welfare of children.
Serious case reviews are not enquiries about how a child died or was seriously harmed, or into who is culpable. These are matters 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. A SCR may be conducted at the same time, but should be seperate from disciplinary action. In some cases it may be necessary to initiate disciplinary action as a matter of urgency to safeguard and promote the welfare of other children.
When a child dies or is seriously harmed and abuse or neglect is known or suspected, the first priority must be to consider immediately whether there are other children who are likely to be placed in the same situation. Where there are concerns about the welfare of siblings or other children the guidance in Chapter 6 of these procedures must be followed.
13.2 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. This is irrespective of whether Children's Social Care is or has been involved with the child or family. This should include a child who has been killed by a parent, carer or close family relative:
- with a mental illness
- known to misuse substances, or
- perpetrate domestic abuse
When should the LSCB consider undertaking a SCR?
The LSCB should also consider a review whenever a child has been harmed in the following situations:
- A child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; or
- A child has been seriously harmed as a result of being subject to sexual abuse; or
- A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004, or
- A child has been seriously harmed following a violent assault by another child or adult:
the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. This includes interagency and/ or inter disciplinary working.
Questions to ask which may help in deciding if a SCR could yeild useful lessons
- Was there clear evidence of a child having suffered, or been likely to suffer significnat harm that 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 or neglected in an institutional setting (e.g. school, nursery, family centre, Young Offender Institution, Secure Training Centre, immigration removal centre, mother and baby prison unit, children's home or armed services training establishment)?
- Was the child abused or neglected while being looked after by the local authority?
- Was the child a member of a family that has recently moved to the UK, for example an asylum seeker or temporary worker?
- Did the child suffer harm during an unauthorised absence from an institution or having run away from home or care?
- Does one or more agency or professional consider that its concerns about a child's welfare were not taken 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 promulgated, understood or acted up?
13.3 Which LSCB should take responsibility?
Where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is or was normally resident should take lead responsibility for conducting the SCR. Any other LSCBs that have an interest or involvement in the case should cooperate as partners in jointly planning and undertaking the SCR.
13.4 Looked After Children
In the case of looked after children, the local authority which has responsibility for the child should exercise lead responsibility for conducting the SCR, 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.
13.5 Action to be taken when a child dies or is seriously injured
Any agency or professional may refer a case to the LSCB where it is believed the criteria for a Serious Case Review are met. Notification should be made to the LSCB Manager, who will inform and discuss the case with the Chair of the SCR Sub Group. The notification will be reviewed by the SCR Sub Group in line with these procedures and Working Together 2013. The SCR Sub Group will then make a recommendation to the Chair of the LSCB. In some cases the criteria will be clearly met and the Chair will decide immediately that an SCR should be conducted.
All child deaths should be reported to the CDOP Business Support Manager. It is their responsibility to inform the LSCB Manager. Any professional who becomes aware of a child who has died or has been seriously injured and abuse or neglect is suspected must complete a Serious Incident Notification Form which should be sent to the Safeguarding Unit to inform them of the death or injury.
Considering a Notification
When a notification is made, the LSCB Manager will liaise with the Chair of the SCR Sub Group and all relevant agencies asking them for a short report indicating their knowledge of the child and the family and any relevant information regarding the notification. The reports will be presented at the first available Sub Group meeting after the notification. A decision to undertake a SCR will depend on the information from the notification and the information from the reports. It is important that agencies do the relevant checks of their involvement and present accurate written information to the Sub Group. This written information will form part of the minutes of the meeting. It is likely that the SCR Sub Group Chair will need to present this information to the Overview Report Writer if an SCR is agreed with the minutes of the meeting where the SCR was considered.
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 files 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.
13.6 The Serious Case Review Panel
The Chairperson of the SCR Panel in North Yorkshire is currently the legal advisor to the LSCB. It is desireable for the chair to be someone who is not representing Social Care, Police, Education or Health as these agencies have a major role in any Serious Case Review.
The Sub Group members include:
- LSCB Legal representative
- Head of Safeguarding - Children's Social Care
- Principal Education Social Work Manager, Children and Young People's Service
- DCI Protecting Vulnerable Person's Unit, North Yorkshire Police
- North Yorkshire LSCB Manager
Frequency of Meetings
The Sub Group will meet once every three months and additionally if required.
Function of the SCR Panel
The SCR Sub Group can make the following recommendations to the Chair of the LSCB:
- To convene an individual panel to undertake a SCR
- To defer the decision until more information is available ( a date should be fixed for futher consideration - cases must not be deferred generally)
- To require agencies to undertake internal management reviews
- To undertake a smaller scale audit of cases which do not meet the criteria of SCR
- To undertake a non statutory review.
The LSCB Manager should forward the recommendation to the LSCB Chair within 5 working days of the Sub Group meeting.
The LSCB Chair is ultimately responsible for deciding whether or not to conduct a SCR. Where there is disagreement between any of the Sub Group members or between the Chair and the Sub Group, the LSCB Chair will have the final decision.
The decision to initiate a SCR should not routinely be delayed because of outstanding criminal proceedings or Coroners Hearings.
If the decision is to initiate a SCR, no member agency should comment publicly upon the case without prior consultation with the Chair of the LSCB.
Decision to hold a SCR
Where a decision has been made to hold a SCR the LSCB Manager will write to the Chief Executive or equivalent of all the known relevant agencies informing them of the decision and asking them to commence an Individual Management Review. They will ask each known relevant agency to secure both paper and electronic files relating to the case. If for any reason a decision is taken not to undertake a SCR, the LSCB Manager will inform all known relevant organisations to rescind the instruction to secure all relevant files.
The designated Nurse will inform the commissioning arm of the PCT, Strategic Health Authority and all other health providers. The DCI for North Yorkshire Police will inform the HMIC. The LSCB Manager will write to the Chief Probation Officer to inform him/her of the SCR, they in turn will inform the HMI. The LSCB Manager will write to the LSCB Executive Members, Chair of the Children's Trust and Chief Executive of North Yorkshire County Council informing them that a SCR is being undertaken within 5 working days.
Notification to the Department of Education
The LSCB Manager is responsible for ensuring that immediately following the decision, there is formal notification to Ofsted that a SCR will be taking place.
13.7 Responsibilities of the SCR Sub Group
Once a decision has been made the SCR Sub Group should consider a number of relevant issues:
- The scope of the review process for the individual case. This will form the Terms of Reference.
- Who will Chair the individual panel ( this person must be independant of the LSCB).
- Who will sit on the individual panel.
- Who will be commissioned to undertake the Overview Report ( again, this person must be independent of the LSCB).
- Timetable for the single agency Chronologies.
- Timetable for the multi-agency Chronology.
- Timetable for completion of the individual IMR's
The timetable should be provisional and take into account that Ofsted require SCRs to be completed within six months of notification.
The LSCB Manager will be ultimately responsibile for securing an Independent Chair and Overview Report Writer.
13.8 SCR Individual Panel Membership
Individual SCR panels will be chaired by the Independent Chair. The timetable will be agreed at the first meeting with the Overview Report Writer. To be transparent and in line with a SCR recommendation, the panel will consist of different members to the standing SCR Sub Group. Once the Chair has agreed a SCR, the Executive Group will be asked to nominate a senior person from their organisation to sit on the individual panel. The panel should include:
- Independent Chair of the individual panel
- Independent Overview Report Writer
- The Designated Nurse representing health
- A senior police officer above the rank of all those who were part of the case
- A senior representative from the Education Service
- A senior member of Children's Social Care
- A professional from an agency which has no involvement with the SCR
- LSCB Manager
Role of the Individual Panel
The role of the individual panel can be complex and therefore it is important that the right people are appointed. Members should be sufficiently experienced in safeguarding, credible to both the Board and their own organisation and have sufficient seniority to be accountable for organisational change. Their role is to critically reflect on the Individual Management Reviews (IMR's) and the multi agency chronologies and to pull from the information provided, with the Overview Report Writer, the lessons learned. It is also to help the Overview Report Writer understand from the different agency perspectives how and why something happened in the child's case.The expectation is that all panel members will have seniority or equal seniority to their IMR report writer. A SCR is a time consuming affair. It is important that the individual panel members can attend all the meetings and can attend meetings at short notice. It is likley that there will be no more than 3-4 full days.
At the first meeting of the individual panel each agency should have identified their own IMR writer. The IMR writers will be asked to meet with the Overview Report Writer. At this meeting a definitive timetable will be drawn together. Each IMR writer will have a copy of the IMR Booklet giving details of the format and advice on chronologies etc. A known list of acronyms will be provided by the LSCB Administrator. Details of what to do when an IMR writer comes across a name not on this list will be provided at the meeting. The Overview Report Writer will give an overview of what they are looking for in the IMRs and the chronologies. A list of at least four meetings will be agreed between the individual panel and the Overview Report Writer to look at the IMRs and the multi agency chronology. This will be in keeping with the overall timetable.
The subsequent meetings will be in each panel members diary. The panel cannot operate without all members attending the meetings. If a member can not attend all the meetings then their agency must decide if they are the appropriate person to be on the panel. A substitute of equal status might be considered in very rare circumstances.
13.9 Individual Management Reviews (IMRs)
It is not the responsibility of the panel or of the Overview Report Writer to correct IMRs. All IMRs should have been signed off by their respective agenciesbefore they are presented to the panel. Changes can be made after the presentation but only if a question has arisen that might not otherwise have been addressed. Therefore it is important for IMR writers to attend the meetings with the Overview Report Writer. It is at this point that questions and clarification will be sought by the Overview Report author.
13.10 Timescales for initiating aand undertaking a SCR
The SCR must be completed within six months of the notification to Ofsted, unless an alternative timescale is agreed with the Ofsted Safeguarding Unit. Sometimes the complexity of the 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 there should be a discussion with the Safeguarding Adviser to agree a new timetable. This is dependent on a revised update and project plan. This update should include recommendations for action that are not dependent on the SCR being concluded.
In some cases, criminal proceedings may follow the death or serious injury of a child. The LSCB Manager should discuss with the relevant criminal justice agancies at an early stage how the process should take account of such proceedings, their potential impact upon the criminal investigation and who should contribute and when. The progress of SCRs should not be routinely delayed because of outstanding criminal proceedings or Coroner's Hearings. In some cases it may not be possible to complete or to publish a review until after the Coroners' investigation or criminal proceedings have been completed. However, this should not prevent early lessons from being implemented.
13.11 Information to the individual SCR Panel
It is crucial that the panel and the Overview Report Author have access to all relevant documentation, and where necessary individual professionals, to enable both to effectively undertake their SCR functions. This may include commissioning a specialist. If the Overview Report Author feels that a specialist opinion is required and it has not been included in the Terms of Reference, it must firstly be agreed with the Chair of the SCR Sub Group and the Chair of the LSCB.
If new information becomes available regarding any case under discussion by the SCR Panel, that information must be forwarded to the LSCB Manager in report format as a matter of urgency.
Health Overview Report
The commissioning arm of the PCT will put together a Health Overview Report for the Strategic Health Authority and the health providers. This report should be completed in time to inform the LSCB Overview Report.
13.12 Completion of the SCR
Once the Overview Report has been completed the SCR Sub Group and individual panel should meet with the Overview Report Author to discuss the draft report and Executive Summary. Any changes or interpretations should be made at this meeting. However if subsequently the report is re-distributed and/or further amendments are requested by members they must be attached to the final set of minutes. This allows for transparency and provides an audit trail of Ofsted announced inspections. The LSCB Action Plan should also be put together at this meeting by panel members. The Overview Report, Executive Summary and Action Plan should be presented at the first available Executive Meeting. If an Executive Meeting is not due a special meeting should be called. The LSCB should receive the Executive Summary and Action Plan at the next scheduled meeting.
13.13 Executive Board responsibilities on receiving the SCR
On receiving the Overview Report, Executive Summary and LSCB single agency action plans, the Executive Group should:
- Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the Overview Report;
- Agree the LSCB Action Plan;
- Agree a process for implementation, review and audit;
- Agree arrangements to provide feedback and de-brief staff, family members and media;
- Agree a strategy for disseminating key findings and recommendations;
- Decide whether the Overview Report should be published.
Two hard copies of the full SCR, including the multi-agency chronologies, IMRs, Health Overview Report and Action Plans to be sent to Ofsted by registered post.
13.15 Overview Report, Action Plan and Executive Summary
An anonymised copy of the Overview Report and the Executive Summary will be made public by placing the summary on the LSCB website. This will take place after the LSCB has received the Ofsted Evaluation Letter and must be timed in accordance with the conclusion of any related Court or Coroner proceedings. It should include the names of the LSCB Chair, SCR Panel Chair, the Overview Report author and job titles and employing organisations of all the individual panel members. However, the LSCB Executive Group can decide not to publish the full report if, in their judgement, it would identify family members or cause distress or place any child at risk.
13.16 Monitoring and Audit
The Overview Report, the LSCB Action Plan, multi agency chronology and the IMRs will be sent to Ofsted for evaluation. If the Evaluation Letter indicates adequate or above then no further action will be taken by Ofsted. However if the Evaluation Letter indicates inadequate, a new SCR Panel with a new Independent Chair will be convened to reconsider the review. A new Action Plan to address the inadequacy of the review will be completed and presented to Ofsted within three months.
In line with arrangements between inspectorates, the outcomes of reviews will be shared with CQC, HMI and HMIC.
The Overview Report and the Executive Summary can not in normal circumstances be released until after the Evaluation Letter has been sent to the Chair of the LSCB. However local circumstances may dictate that the LSCB publish the Executive Summary prior to the completion of the Ofsted evaluation. Also, the LSCB may wish to take account of any points raised by the Ofsted Evaluation Letter before publishing the Executive Summary. This decision will be made by the LSCB Chair and the Executive Group.
Monitoring of the Action Plans produced from the Overview Report and the single agency IMR's will be undertaken by the SCR Sub Group reporting to the Executive Group.
Any areas of inter agency activity identified as a particular concern should be referred for consideration by the Performance Sub Group as a potential area for future audit and research.
13.17 Accountability and Disclosure
The LSCB should consider carefully who might have an interest in SCRs - for example elected members and appointed members of the authorities, staff, the child who was seriously harmed and the subject of the SCR, members of the child's family, the public, the media - and what information should be made available to each of these interests.
These are difficult interests to balance including:
- The need to maintain confidentiality in respect of personal information contained within the 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 ongoing, in that providing access to information may not be within the control of the LSCB.
The principle that that information to be published will if possible be shared in advance with those affected.
It is important to anticipate requests for information and plan in advance how they ahould be met. For example, a lead agency may take responsibility for de-briefing family mambers.
When setting the terms of reference for a SCR, a media strategy should also be agreed. It is usual for the Police to take forward any media involvement around criminal matters and the LSCB to take forward media involvement around the SCR itself. The LSCB has a service level agreement with the local authority media team to take this forward on their behalf.
13.19 Reviewing Institutional Abuse
When serious abuse takes place in an institution or multiple abusers are involved the same principle of review applies. SCRs in these circumstances are likely to be more complex on a larger scale and may require more time. It may take longer to put together the TOR as it will need to be carefully constructed to explore the issues relevant to the specific case. Extra time may be needed to complete chronologies and IMRs.
There needs to be clarity over the interface of the different processes of investigation (including criminal investigations), case management, including help for the abuse children and immediate measures to ensure that other children are safe. An Initial Meeting has been called by the Chair of the LSCB to decide who has lead responsibility for each of the three strands. These three different processes should inform each other. Any proposals for review should be discussed with those leading criminal investigations to make sure that they do not prejudice criminal proceedings. However a SCR should not be held up due to a criminal investigations especially if there are likely to be lessons to be learned that will help to safeguard other children.
13.20 Serious Incidents
All serious incidents must be reported to the LSCB Safeguarding Unit. These incidents include:
- Cases brought to the attention of Ofsted and the Secretary of State because of concerns about professional practice or implications for government policy;
- Cases which raise issues about the Council's professional practice that may need to be considered further in the context of performance assessment;
- Cases which have attracted or are likley to attract media attention.
The definition of a Serious Child Care Incident includes;
- Death of a child accommodated in the home, residential unit, placed with foster carers 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 of an individual working at the home.
- Serious illness or serious accident sustained by a child accommodated in a children's home, residential family centre, placed with foster carers 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 carers involved in child sexual exploitation (prostitution).
- Serious incident that requires Police to be called to the home;
- Allegations that a child has committed a serious offence;
- Any serious complaint about the home or persons working there, or serious complaint about any foster carer approved by a fostering agency;
- Instigation or outcome of any child protection enquires involving a child accommodated at the home or a child placed with foster carers.
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 and ask them to complete as far as possible a 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 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 Performance Sub Group to monitor and evaluate trends and lessons learned.
Serious incidents that take place in residential units will be reported to the Manager for Residential Services and will not be covered by the procedures.
Decisions not to proceed to a Serious Case Review
If the Chair of the LSCB decides that the criteria for the SCR is not met a decision should be made about the appropriateness of conducting a review to look at whether lessons can be learnt. This may involve one or more agencies and is known in North Yorkshire as an Internal Review.
As far as possible the same standards and ways of working as described above should be followed. However the main difference is that agencies not involved in the review may be asked to provide a Chair and Overview Writer. 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 an Internal Review to inform both its judgements on an inspection. In such cases the relevant information should be made available to the SCR Sub Group within six months.
Learning Lessons Locally
As the purpose of SCRs is to learn lessons for improving both individual agency and inter agency working, it is essential that the lessons are learned and acted upon. This means that at least as much effort should be spent on implementing the recommendations as on conducting reviews. The following may be helpful:
- As far as possible the review should be conducted so that the process is a learning exercise in itself for all those who have been involved in the case;
- The type and level of information which needs to be disseminated;
- How and to whom this information should be disseminated;
- It should include both good and poor practice;
- Areas where change is required;
- How this information will be integrated from other Serious Case or Internal Reviews;
- Incorporate the learning into Training Programmes;
- Recommendations should be few in number, SMART and concentrate on key areas
Additionally, the LSCB will run briefing sessions after each SCR or Learning Lessons Review to ensure lessons are disseminated. IMR Authors are required to feedback and share their Action Plans with all those involved in the individual IMRs before the Overview Report is completed. Once the Overview Report has been completed, IMT authors should feed back the findings to their respective agencies.
Learning Lessons regionally and nationally
Taken together, child deaths and SCRs should be an important source of information to inform national policy and practice.
The Department of Education is responsible for identifying and disseminating common themes and trends across regions and nationally and acting on lessonsfor policy and practice. The Department of Education commissions Overview Reports every two years drawing out the key themes on SCRs and their implications.Ofsted produce a report every six months on the quality of SCRs. The LSCB will include in their briefing sessions any new lessons, policy implications and national procedural changes. If the LSCB has not had an SCR in the past year the LSCB Training Plan will include national and regional lessons and updates.
The SCR 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 about the 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 the Independent Chair?
What time period should be reviewed ( 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 can be achieved (specialist hospital trusts may be involved in SCRs 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 can be achieved.
Whether and how to involve family mambers 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 reviews).
How should the relevant process take account of the Coroners inquiry and ( if relevant) any criminal investigations or proceedings related to the case? How best to liase with the Coroner and the CPS?
How should any public, family or 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 the new information emerges.