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8.2 Serious Case Review Process Practice Guidance

RELEVANT CHAPTER

Serious Incident Review Group Procedures

This chapter was added to the manual in July 2018.


Contents

1. Introduction
2. What is a Serious Case Review?
3. What is a Notifiable Incident?
4. Serious Case Review Process – Key Stages
  4.1 Stage 1 - Reporting of a Notifiable Incident
  4.2 Stage 2 - Reporting an Incident for Consideration of a Serious Case Review
  4.3 Stage 3 - Initial Assessment Process
  4.4 Stage 4 - The SCR Assessment Process
  4.5 Stage 5 - Commissioning a Serious Case Review
  4.6 Stage 6 - Engaging with Family Members
  4.7 Stage 7 - The Learning Event
  4.8 Stage 8 - The Serious Case Review Report
  4.9 Stage 9 - Governance
  4.10 Stage 10 - Publication of the Report
  4.11 Stage 11 - Notifying Ofsted and Other Agencies
  4.12 Stage 12 - Learning


1. Introduction

Regulation 5 of the Local Safeguarding Children Board Regulations 2006 sets out the functions of Local Safeguarding Children Boards (LSCBs). This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. The commissioning of such reviews is a statutory requirement for the LSCB.

This document has been prepared to provide a consistent approach by LSCBs across Merseyside following notification of a case that may fit the criteria for a serious case review (SCR).


2. What is a Serious Case Review?

Regulation 5(1) (e) and (2) of the Local Safeguarding Children Board Regulations 2006 set out an LSCB’s function in relation to serious case reviews, namely.

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

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

  1. Abuse or neglect of a child is known or suspected; and
  2. Either –
    1. the child has died; or
    2. the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or relevant persons have worked together to safeguard the child.


3. What is a Notifiable Incident?

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).


4. Serious Case Review Process – Key Stages

The following stages will be followed on receipt of information that a case may be appropriate for a serious case review:

4.1 Stage 1 - Reporting of a Notifiable Incident

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

4.2 Stage 2 - Reporting an Incident for Consideration of a Serious Case Review

Notification of an incident that fits the criteria for SCR, which is received from Children’s Social Care or a partner agency, will be brought to the attention of the Local Safeguarding Children Business Unit.

The practitioner making the referral will submit a referral form (see Referral Form for Serious Incident Review Group Consideration of a Case Review) which will be forwarded to the LSCB Business Manager.

4.3 Stage 3 - Initial Assessment Process

The LSCB Business Manager will facilitate a triage process in consultation with the Chair of the respective LSCB Review Group and a nominated professional who will consider whether the case meets the SCR criteria and make appropriate recommendations to the respective LSCB Review Group.

A written account of these recommendations, setting out supporting rationale will be forwarded for consideration by the respective LSCB Review Group.

The independent LSCB chair should be appraised at an early stage of the referral.

4.4 Stage 4 - The SCR Assessment Process

The LSCB for the area in which the child is normally resident should decide whether an incident notified to them meets the criteria for an SCR. This decision should normally be made within one month of notification of the incident.

  • The referral will be considered as an agenda item at the subsequent meeting of the respective LSCB Review Group. In urgent cases or matters of high public interest the Chair of the group may consider convening an extraordinary meeting to discuss the referral;
  • The chair of the respective LSCB Review Group will ensure that representatives of the agencies attending the meeting have familiarised themselves with their respective agencies involvement in the case and have sufficient knowledge of the case to enable the sub group to make an informed decision;
  • A decision whether to recommend a serious case review wild be made at the respective LSCB Review Group meeting;
  • A written record of the decision by the group with supporting rationale will be recorded in the minutes of the meeting;
  • The Chair of the respective LSCB Review Group will ensure their recommendation and supporting rationale to commission a serious case review is forwarded to the independent chair of the LSCB, who will determine whether to undertake a serious case review;
  • The LSCB Chair will ensure that Ofsted, DfE and the National Panel of Independent Experts are informed in writing within five working days of their decision;
  • The chair of the LSCB will write to members of the LSCB board to advise them of the decision to commission a serious case review;
  • Where a case does not fit the criteria for a serious case review, the chair of the the respective LSCB Review Group will consider if there are any learning opportunities that can be achieved from the case;
  • In this instance the chair will consider recommending to the LSCB chair a local practice review or other means of cascading the learning;
  • Any learning from the case will be considered in line with the learning improvement framework.

4.5 Stage 5 - Commissioning a Serious Case Review

In the event of the LSCB Chair agreeing to commission a serious case review, the LSCB Business Unit Manager will facilitate the following lines of enquiry:

  • Identify one or more suitably qualified and independent reviewers to conduct the review in an agreed manner. The LSCB should be satisfied that the reviewer has demonstrated that they are suitably qualified and is independent of the LSCB and organisations involved in the case;
  • Determine appropriate terms of reference in consultation with the Chair of the LSCB, the Chair of the respective LSCB Review Group and the reviewer;
  • Identify appropriate multi-agency representation at the review panel. The LSCB chair should ensure that there is appropriate representation in the review panel of professionals and organisations who were involved with the child and family;
  • Determine roles and responsibilities of the reviewer, methodology, report format and completion of an action plan;
  • Determine appropriate timescales for completion of the SCR. This should be within six months of initiating the review;
  • Facilitate a written contract between the reviewer and the respective LSCB Review Group, taking cognisance of local procurement rules;
  • Request Chronologies from relevant agencies concerned in the case.

4.6 Stage 6 - Engaging with Family Members

The reviewer will ensure that the family or those with parental responsibility for the child/children affected by the review are informed that a serious case review has been commissioned. The family or those with Parental Responsibility will be provided with a letter of introduction and an information leaflet explaining what happens in a serious case review. The reviewer will decide an appropriate time to meet the family or those with Parental Responsibility of the child. If family members have relevant information that may assist the review, they should be encouraged to participate.

4.7 Stage 7 - The Learning Event

The chronologies collated by the LSCB Business unit will be assessed by the reviewer, which enable him/her to identify key lines of enquiry.

A key objective of the serious case review process is to identify and disseminate learning from the case.

The reviewer will facilitate a learning event attended by the review panel and practitioners who had involvement in the case.

The chair of the review panel LSCB should ensure that there is appropriate representation in the learning event of practitioners and organisations who were involved with the child and family.

The reviewer should adopt the following principles of learning and improvement, which are set out in ‘Working Together to Safeguard Children':

  • 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.

The focus of the learning event is to enable practitioners to share their understanding of what happened and identify key learning points for future practice.

Using a systems approach the reviewer will focus the learning around clearly defined key themes including:

  1. Assessment;
  2. Decision making;
  3. Actions;
  4. Communication;
  5. Cooperation between agencies;
  6. Areas of good practice;
  7. Areas for improvement.

The reviewer may consider it appropriate to conduct one to one discussions with some practitioners, particularly in respect of certain sensitive matters.

Any immediate risks identified by the reviewer will be brought to the attention of the relevant agency promptly.

4.8 Stage 8 - The Serious Case Review Report

  • The reviewer will complete a draft report. It should provide a sound analysis of what happened in the case, identify any learning and if appropriate make recommendations aimed at reducing any future risk;
  • It should be written in plain English and in a way that can be easily understood by professionals and the public alike. It should be suitable for publication without needing to be amended or redacted;
  • SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case;
  • The report will be forwarded to the respective LSCB Review Group, who will provide feedback and any suggested amendments;
  • The respective LSCB Review Group will then approve the report and forward it to the LSCB board for review;
  • The main board will provide feedback and any suggested amendments;
  • The Reviewer will be invited to present their findings to the main board;
  • When they are satisfied with the findings and recommendations, the LSCB board will approve the report.

The reviewer and a member of the review panel will meet with the family or person with parental responsibility to share with them the completed report and invite comment.

4.9 Stage 9 - Governance

The respective LSCB Review Group will convene and agree with partners what action they need to take in light of the review findings.

Any actions plans arising from recommendations should be S.M.A.R.T and linked to the strategic priorities of the LSCB.

Actions raised should include agreed timescales for completion and desired outcomes.

The action tracker will be updated to reflect the decisions made by the group.

4.10 Stage 10 - Publication of the Report

The Chair of the LSCB will consider whether it is necessary and proportionate to publish the report. Any decision, with supporting rationale, should be recorded in writing by the LSCB Chair.

As a general principle, reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months.

Thereafter the report should be made available on request.

The Chair of the LSCBs 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.

In considering whether to publish the report, LSCB chairs should consider carefully the impact of publication on children, family members and others affected by the case and what steps can be taken to mitigate that potential risk.

The views of the child, the family or any person with parental responsibility should be considered by the Chair of the LSCB

The LSCB must comply with the Data Protection Act 2018 in relation to SCRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders.

The timing of publication should have due regard to the impact on any ongoing legal proceedings, including any inquest.

In the event of a report not being published the LSCB chair will consider the most appropriate means of disseminating any learning that may be present in the case.

4.11 Stage 11 - Notifying Ofsted and Other Agencies

The LSCB chair 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 the LSCB chair considers that an SCR report should not be published, they should inform DfE and the national panel, who will provide advice on the matter.

The LSCB should provide all relevant information to the panel on request, to inform its deliberations. In cases where an LSCB is challenged by the panel to change its original decision about publication, they should inform Ofsted, DfE and the National Panel of their final decision.

The family or any person with parental responsibility should be informed of the decision LSCB Chair of the LSCB in respect of publication.

4.12 Stage 12 - Learning

A published report will be posted on the LSCB website and readily accessible for a minimum of twelve months. Thereafter, the report should be made available on request.

The LSCB Business Manager will complete an executive summary containing a precis of the case, key learning recommendations and actions taken.

In respect of a published report the Executive report will be published on the LSCB web site.

The LSCB should consider disseminating learning through other means including seven minute briefing, 60 minute briefings, newsletters, social media, conferences etc.

LSCB’s should consider using their respective evaluation processes to measure the impact of any learning from serious case reviews.

See also Multi-Agency Reflective Review Policy.

End