8.1 Serious Incident Review Group (SIRG) Procedures

1. Introduction

A Serious Case Review (SCR) is conducted by the Knowsley Safeguarding Children Partnership into specific cases where the criteria set out in Chapter 8 of 'Working Together' (2010) are met (see: Criteria for a SCR) in order to consider whether there are any lessons to be learnt from the case regarding the ways in which agencies work together to safeguard and promote the welfare of children.

The purpose of undertaking a SCR, therefore, is to:

• Establish whether there are lessons to be learnt 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 both within and between agencies, how and within what timescales 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 and promote the welfare of children.

A SCR is not an enquiry about how a child has died or was seriously harmed or into who is culpable. Such questions will be addressed by coroners and criminal courts.

A SCR is also not an 'investigation' into individual staff and their actions or 'inactions' - these matters should be dealt with under the disciplinary or capability procedures of individual agencies.

A SCR should be conducted in a manner that is sensitive to both the child,(if the review does not involve a death), the family of the child concerned and also those staff who have been involved with the family and takes account of issues relating to race, culture, religion and disability.

The whole process should:

• Reflect the CHILD (e.g. What was the child's world like? When were the opportunities for the child to speak out?);
• Be a learning process which holds agencies and individuals to account;
• Demonstrate transparency and independence at every stage.

2. Criteria for a Serious Case Review

The KSCP will always undertake a SCR where a child dies and abuse or neglect are known or suspected to be a factor in the death.

Additionally KSCP will consider whether a SCR should be conducted where:

• A child sustains a potentially life threatening injury through abuse or neglect or, serious sexual abuse or, sustained serious and permanent impairment of health and development through abuse and neglect; or
• A child has been seriously harmed as a result of being subjected 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 perpetrated by another child or adult.

AND

The case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promoted the welfare of children. This includes inter-agency working and /or inter-disciplinary working.

In addition, the Secretary of State for Education has power to require an inquiry to be held under the Inquiries Act 2005

Where more than one Knowsley Safeguarding Children Partnership (KSCP) has knowledge of the child, the KSCP for the area where the child is or was normally resident should take lead responsibility for conducting any SCR. Any other KSCPs 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 responsible authority should exercise lead responsibility for conducting any SCR, again involving other KSCPs with an interest or involvement.

The following sections relate purely to the process of SCRs and do not detract in any way from the primary purpose of protecting children. It is essential that the usual Child Protection procedures are followed in respect of any other children who may be in need of protection (e.g. for siblings).

3. Links with the Coroner

All unexpected deaths are notified to the coroner who having investigated the circumstances may decide to hold an inquest. A proportion of these deaths may relate to children who fall within the criteria for a SCR. For further information please see Merseyside Joint Agency Protocol: Sudden Unexpected Death in Childhood (SUDiC) (for Children aged 0 to under 18 yrs).

The following has been agreed with the coroner in relation to SCRs conducted where a child has died:

• The coroner will advise the KSCP Business Manager of any concerns relating to the death of a child;
• The KSCP Business Manager will advise the coroner when the KSCP has decided to hold a SCR;
• Appropriate communication will be maintained whilst Coronial and SCR processes continue in line with respective regulations/ procedures to ensure neither process is compromised.

4. Action when a Child Dies/ is Seriously Injured

Any professional may refer a case to the KSCP (after appropriate consultation with his/her line manager or agency designated or named professional) where it is believed that the criteria for a SCR may be met (see Section 2, Criteria for a Serious Case Review). If so:

• That agency's KSCP representative must immediately inform the Chair of the SIRG and/ or the KSCP Business Manager;
• The Chair of the SIRG/ KSCP Business Manager will inform the Director of Children & Family Services/ the Chair of KSCP verbally and in writing.

Where the criteria for a SCR appear to be met, the KSCP Business Manager will then ensure that these procedures are followed within the timescales laid down and will inform OFSTED of the situation and the possibility that a SCR may be held.

The KSCP Business Manager or nominated representative will also liaise with the relevant agencies as appropriate including as a minimum the Police, Children's Social Care Services, Health, and Legal Services. The agency representatives consulted will normally be the agencies' representatives on the KSCP Serious Incident Review Group (SIRG). Where the child in question has died, there will also be contact with the Coroner's office, to ascertain whether abuse or neglect was a known or suspected factor in the child's death or serious injury.

The agency representatives will conduct a 'rapid review' of the circumstances of the case and collate sufficient information relating to their own agency's involvement with the family to assist the Chair of the SIRG and Chair of KSCP to make a decision as the whether the SIRG should be convened. If it is agreed that a SIRG will be convened SIRG members will be required to collate sufficient information from their agency to enable a decision to be made as to whether the criteria for a SCR are met.

In some cases, where the criteria are clearly met, the KSCP Chair will decide immediately that a SCR should be conducted.

5. Notification of Incidents to Secretary of State, Safeguarding Group (DfE) and Ofsted

As of 21 February 2011, the notification arrangements for SCRs have changed. The Safeguarding Group at the DfE have replaced the role of Government Office in relation to notification arrangements. In order to keep ministers briefed, the Safeguarding Group should be informed of:

• New childcare incidents notified to Ofsted as being serious enough potentially to lead to SCRs and other cases which are receiving significant media attention;
• Decisions to initiate SCRs and information on planned completion dates and plans for publishing Executive Summaries and (for SCRs initiated after 10 June 2010) Overview Reports; and
• Where known, expected dates of court proceedings related to child protection incidents and the outcome of court cases including verdicts and sentencing.

The Safeguarding Group may also seek further ad hoc information from KSCPs. For further information please see letter from Jeanette Pugh to LSCP Chairs, 10 February 2011.

The criteria for notifying Ofsted and the Safeguarding Group (DfE) are laid out in Appendix A - Notification of Incidents to Secretary of State, Safeguarding Group (DfE) and Ofsted.

When an incident which meets these criteria are brought to the attention of the KSCP Chair/ SIRG Chair, the KSCP Business Manager will telephone Ofsted to register the incident and then compose and post the notification within 48 hours of the incident coming to notice.

If the notification is made in order to advise of a case which is likely to attract media attention but is unlikely to become subject of a SCR then this should be made clear within the notification, together with the rationale as to why the criteria for a SCR are not met and this will satisfy the need for any further update.

If the incident is to be considered for a SCR then the outcome of those considerations must be notified, in writing, to Ofsted and in a brief e-mail to the Department for Education. If the outcome of the considerations is not to convene a SCR then the rationale behind that decision must be made clear.

6. Securing Files

If it appears that the criteria for a SCR may be met, the KSCP Business Manager, with the approval of the Chair of SIRG, will send a letter/ e-mail (on behalf of the KSCP Chair) to the Board representatives or equivalent of the relevant agencies with copies to the named professionals, within 2 working days of receiving notification of the child's death/serious injury and relevant concerns, to request agencies to secure files.

The letter will include (where available):

• Names, dates of birth and addresses for the child and other children;
• Names, dates of birth and addresses of the parents/carers and key adults;
• Brief circumstances of the case;
• School attended;
• GP Practice.

All partner agencies will need to have appropriate procedures in place for securing relevant files to prevent contamination of information. Where possible, the files should be secured by someone who is in a senior position and does not have line management responsibility for the case. The files should be photocopied and the copy left with the practitioner, the original (where available) will be the file which will be secured and used for the Individual Management Report. Where possible this should include all contemporaneous notes (and any handwritten, dictated or electronic notes not yet placed on the file) and consideration should also be given to including legal files. Where records are electronic, arrangements should be made to ensure that the file record, as stored at the point the decision is made to secure files, should be retrieved and made available to the KSCP Business Manager as a paper file and that appropriate action is taken to ensure that the electronic file cannot be altered from this point.

Where a SCR is held, records must remain secure until the completion and ratification by the KSCP of the Overview Report.

Where care proceedings have commenced and CAFCASS files are required, these must be requested from the court as they are considered Court property. In this case CAFCASS will write to the Court to request permission to use the information in the files for the purpose of a SCR.

It will be the responsibility of each agency, and not the KSCP, to ensure that files are secured and safely stored and to be made available as required.

7. Serious Incident Review Group (SIRG)

Terms of Reference

1. Purpose

The SIRG sub- group supports the KSCP to:

• Comply with statutory responsibilities in accordance with the Children Act 2004, the Local Safeguarding Children's Board Regulations 2008, Working Together to Safeguard Children 2018;
• To establish the need for and recommend if a Serious Case Review and / or any other review is required further to analysis of referred cases and in accordance with the threshold identified in Working Together to Safeguard Children 2018.

2. Key objectives

• To receive notifications / referrals of cases to be considered for review;
• Establish, develop and maintain partnership policies, procedures and guidance in response to notifications to the SIRG;
• The SIRG Members will undertake the functions of the Serious Case Review Criteria Panel;
• The Chair and Business Manager will initially consider / triage all case referral notifications. Relevant cases will be heard by the Panel within the nationally agreed timescales from notification (1 month);
• The SIRG members will make a recommendation to the Independent Chair of KSCP with regard to the threshold criteria and review status. (The Independent Chair having responsibility for the final decision);
• The SIRG members will convene as the Serious Case Review Panel and will be responsible for monitoring the quality of work commissioned by the Board from Independent Consultants including authors of reports and Chairs of the review process;
• The SIRG members will ensure that a comprehensive report is presented to the Strategic Board within the identified timescales;
• Lead, monitor and inform the KSCP partnership response to serious case / management reviews and implementation of recommendations made;  achieved by the collation and analysis of qualitative and quantitative data identifying themes, trends and emergent patterns of concern in relation to frontline practice;
• The SIRG will oversee: the dissemination of learning from all reviews and   that impact on practice and outcomes has been assessed by liaison with relevant KSCP Sub Group and any other relevant Pan-Mersey / regional Sub Groups;
• Ensure sub group objectives and action plans are managed in line with statutory requirements and any agreed regional / sub-regional guidance and protocols;
• Oversee and ensure that national and local learning is incorporated into local training and communications;
• Ensure young people and their families are consulted with to identify areas of concern, gaps in service provision to support and enhance review findings and recommendations.

3. Governance

• The SIRG will be chaired by an experienced Independent person. There will be clear accountability through quarterly meetings with the KSCP Chair supported by the Board Manager. It will aim to maintain a diverse membership, and if possible ensure that children's services, health, the police and education are represented. It will seek to involve people with appropriate expertise as necessary; 
• The SIRG will be supported by the Board's Manager and Administrator;
• The SIRG Group will meet at bi monthly, and may meet more frequently if its workload so demands.  It will be expected that members will give appropriate priority to the work of the sub group and that partner organisations will enable them to do this;
• The SIRG will provide a report at least quarterly the Executive. This will include an account of progress, significant findings and issues, future workload, and any recommendations for action or approval by the Board;
• The SIRG will maintain a record of its meetings, including an attendance log;
• The SIRG  will develop a work plan in the context of the Board's overall Business Plan together with any issues that are communicated throughout other National / Regional agendas;
• The SIRG will contribute to the KSCP Annual Report.

4. Chair / Vice Chair

The group will be chaired by the Designated Nurse Safeguarding Children Integrated Care Board. The Deputy Chair is Julie Milburn, Merseyside Police.

5. Responsibilities

• Members share responsibility for meeting the aims and objectives and supporting the work of the SIRG;
• Ensure key messages and information from the SIRG are disseminated to their organisations and other partners as necessary;
• Case Reviews continue to be carried out so that there is a clear focus on  the child's best interests, including communicating any concerns about practice or welfare raised during review to the relevant senior officer(s) at the earliest opportunity;
• They abide by the Information Governance guidelines of the KSCP.

6. Core agency membership

Members will be strategic managers from key partner agencies.

Additional KSCP member agencies may be co-opted onto group if specific / clinical expertise is required for review purposes.

• Designated Nurse Integrated Care Board;
• Head of Service Children's Social Care;
• Safeguarding & Quality Unit;
• Merseyside Police;
• Designated Doctor;
• Named GP;
• Lead for Vulnerable Groups & Safeguarding in Education;
• Lay Member;
• KSCP Business Manager;
• Legal Services Representative;
• National Probation Service  / Community Rehabilitation Company;
• Youth Offending Service;
• Education;
• Public Health.

** Members should not have had direct involvement in the case and will be expected to declare an interest should they have had direct involvement for panel consideration. The Panel will make a recommendation about potential conflict of interests. Any appeal should be made to the KSCP Independent Chair.

7. Quorum and attendance

A minimum of three different agencies must be represented for meetings to be quorate.  NB The health agencies will be counted as one for this purpose.

80% attendance is required by all members, an attendance log will be maintained and persistent failure to attend will be reported to the agency Board Member to address.

See:

Appendix B - Terms of Reference and Scoping

8. Timescales

Where a decision is made to conduct a SCR, the review should be completed within six months unless an alternative timescale has been agreed with the Safeguarding Group. More time may be required, for example where the SCR concerns abuse which has taken place in an institution or where multiple abusers are involved.

Where it emerges during the course of a Review, that the timescale cannot be met, the KSCP Business Manager should formally request a revised timescale which must be agreed by the Safeguarding Group.

In some cases, criminal proceedings may follow the death or serious injury of a child. Those coordinating the review should discuss with the relevant criminal justice agencies, at an early stage, how the review process should take account of such proceedings, for example how does this affect timing, the way in which the review is conducted (including interviews of relevant personnel), its potential impact on criminal investigations and who should contribute at what stage?

SCRs should not be delayed as a matter of course because of outstanding criminal proceedings or an outstanding decision on whether or not to prosecute. Much useful work to understand and learn from the features of the case can often proceed without risk of contamination of witnesses in criminal proceedings. In some cases it may not be possible to complete or to publish an Executive Summary / Overview Report until after Coroner's or criminal proceedings have been concluded, but this should not prevent actions from early lessons learned from being implemented.

9. Individual Management Reviews

Internal IMRs should be completed and forwarded to the KSCP Business Manager having being 'signed off' by a senior officer and having been subject to appropriate decision-making processes within the organisation, within the timescales agreed by the MRG and in any case a maximum of 2 months of the decision to hold a SCR.

The aim of the IMR is to look openly and critically at individual and organisational practice and in so doing to consider if changes in practice need to be made and how this can be done.

As part of IMRs, each agency will:

• Determine who will undertake the IMR. The person must not have been directly concerned with the child or family and must be independent of the line management for the case and must be given sufficient time and resources to undertake the task;
• Have a named person to advise on how to conduct/complete such a Review;
• Ensure all the relevant information is obtained to complete the IMR, each agency to provide written guidance on where information may be located;
• Inform key staff that an IMR is to be undertaken and the process for feedback, support and debriefing, in advance of the completion of the Overview Report. Staff should also be instructed not to disclose any information verbally or in writing to anyone outside the agency unless with prior agreement of the agencies senior management;
• Compile a genogram using the prescribed format;
• Compile a Chronology of all records of involvement including correspondence and telephone calls. The KSCP template for the prescribed format must be used to assist compilation of the composite Chronology. The Chronology should include and summarise each contact, setting out decisions made, services provided, action taken, whether this was in line with expected practice/ procedures and any relevance of each entry to the terms of reference for the Review;
• Conduct interviews of individual staff where required and agreed by the MRG for the purpose of clarifying information obtained from the written records. The conduct of these interviews needs to be sensitively handled and be mindful of any agency disciplinary procedures. A written record of each interview should be made and shared with the interviewee;
• Where, during the collation of information the author of the IMR comes across information that they believe is relevant and informative but outside the dates of the commissioned Report, include such information as background information;
• Compile the report following the prescribed KSCP format. The Report should include reference to the full terms of reference, information on what files were read, who was interviewed and what procedures were referred to;
• Complete an analysis of involvement (with reference to the terms of reference), lessons to be learnt and recommendations which should be set out within an Individual Agency Action Plan. Any immediate action required must be highlighted;
• Submit the completed Chronology, IMR and Action Plan for approval to the senior officer in the agency who has commissioned the report; the senior officer will be responsible for ensuring the quality and accuracy of the report (reference should be made to the current grade descriptors used by Ofsted for evaluating IMRs) and determining any immediate action to be undertaken arising from the recommendations of the IMR, and ensuring that the recommendations are acted upon;
• The designated health professionals should produce an integrated health chronology and a health overview report focusing on how health organisations have interacted together. This may generate additional recommendations for health organisations. The health overview report will constitute the IMR for the ICBs as commissioners;
• On completion of the IMR report there should be a process of feedback and debriefing for the staff involved in the case, in advice of completion of the overview report, and also when the SCR report has been completed and before the Executive Summary / Overview Report is published. Consider the need for a follow-up feedback session where issues for the agency and its staff are raised;
• Consider the need for any disciplinary action.

See Appendix C - IMR Good Practice Guide

10. Management Review Group

The purpose of the MRG is to bring together and collate the information and analysis contained in the Individual IMRs together with any reports commissioned from any other relevant bodies or interests.

Following a decision to convene a SCR the KSCP Chair will commission an MRG chair.

The Chair of the MRG can be a member of the KSCP, should have sufficiently independent of supervisory responsibilities for agencies and professionals involved in the SCR (unless case is sensitive/ high profile and higher level of independence is required) and have a background in Child Protection work.

Membership of the MRG will be recommended by the SIRG and will be set out in the SCR Terms of Reference. The MRG should consist of representatives of the key agencies involved in the case, where possible the person responsible for signing of the agency's IMR). Every Panel should have a representative from Police, Children's Social Care Services, Health, KSCP Business Manager, the Independent Author and access to legal representation as required. In order to provide a range of different views the Panel should also include a representative, with a child protection background, from at least one of the other member agencies of the KSCP.

Panel members should be constant throughout the time of the review and should attend all review meetings.

Chair of the MRG:

The Chair of the MRG can be a member of KSCP but must be independent of the key agencies who have undertaken internal IMRs. The responsibilities of the Chair will include:

• To ensure adherence with the terms of reference;
• To make arrangements in consultation with MRG Members to seek the view of the parents/carer as appropriate;
• To ensure a programme of meetings in line with the timescale for completion;
• To provide regular updates to the chair of the SIRG particularly with the progress and particularly of any delays or potential blockages;
• To complete, following thorough consideration and analysis with the MRG:
  • IMRs, chronologies and Action Plans from each of the Agencies completed in line with KSCP formats and signed off by Senior members of each of the agencies concerned;
  • A composite anonymised chronology;
  • The Overview Report and Executive Summary (See Appendix D - Overview Report Good Practice Guide). For SCRs initiated after 10 June 2010, the Overview Report will be published. For further information please see Tim Loughton's letter to LSCP Chairs.
• To send the draft Overview Report & Executive Summary to other members of the MRG, the Chair of the SCR Panel and the authors of the internal IMRs for comment;
• To ensure the Overview Report & Executive Summary are based on fact and are open, honest and transparent with no suggestion of unfairness - either in the reports or dissemination;
• If any additional enquiries arise, to arrange for these to be answered through the author(s) of the relevant agencies Internal IMR or other appropriate Officer;
• If further concerns e.g. child protection arise during the course of the MRGs work, to inform the Chair of the KSCP/Police/Children's Social Care Services immediately. The MRG must not investigate;
• To ensure clear, robust, meaningful recommendations that will bring about service change;
• To forward the final Overview Report & Executive Summary to the SIRG/ Chair of the KSCP who will consider the report and discuss any amendment or clarification required with the Chair of the MRG and Independent Author before submission to the KSCP for ratification.

Responsibilities of Panel Members:

• To have appropriate experience and expertise;
• To have had no direct involvement with the child or family either as a practitioner or a manager;
• To comply with the Terms of Reference.

Responsibilities of KSCP Business Manager:

• To be a member of the MRG or nominate an appropriate representative and to ensure appropriate administrative support for the MRG;
• To arrange for the preparation of the Composite Chronology;
• To arrange meetings, date, time, venue and refreshments; and arrange for the meetings to be minuted;
• To oversee the anonymisation of chronologies and IMRs.

11. Steps to be Taken When Overview Report and Executive Summary are Complete, including Publication

(This section is subject to revised guidance on independent sign off of Overview Reports and Executive Summaries).

Copies of the Overview Report and Executive Summary will be shared with the Chair and Members of the SIRG to share with Strategic Leads for comment before forwarding to the Chair of the KSCP.

When the final draft Overview Report and executive Summary have been forwarded to the Chair of the KSCP, he/she will arrange for the Overview Report, Executive Summary and Multi-Agency Action Plan to be presented at the KSCP for approval. Prior to doing so the Chair of the KSCP may wish to discuss the Overview Report and Executive Summary with the Independent Author.

Following approval by the Board/ Executive it will be the responsibility of the SIRG, supported by the Business Manager to monitor timely progress and completion of both single and multi-agency action plans. This will require individual agencies to regularly update their action plans. Any undue delay or blockage to the completion of any action(s) should be reported to the Board/ Executive.

The requirement to develop Action Plans should not prevent individual agencies from responding to issues as they arise during the SCR.

The Chair of the KSCP through the KSCP will agree the means by which the Executive Summary is to be made public and confirm if, how and when the parents/carers should be informed of the outcome of the Review and arrangements for them to receive a copy of the Executive Summary.

The Overview Report with Action Plans and the Executive Summary will be disseminated to all Agencies to action and disseminate as appropriate and as agreed by the KSCP.

The KSCP Business Manager will provide a copy of the following to Ofsted / Safeguarding Group:

• Anonymised Overview Report;
• Anonymised Executive Summary;
• Updated Multi-Agency Action Plan;
• Anonymised Composite Chronology;
• Anonymised IMRs;
• Updated Individual Agency Action Plans.

Feedback from Ofsted on the quality of the SCR process will feed into the business planning and training strategy of the KSCP.

Each agency will arrange debriefing for key staff, in particular those who had involvement with the family, in respect of the lessons arising from the report.

A strategy will be developed for responding to any media interest in the case.

The lessons to be learnt from SCRs are to be collated annually by the KSCP SIRG and the results of this exercise are to be reported to the KSCP and disseminated to partner agencies.

The progress of the Multi-Agency Action Plan will be monitored by the KSCP through the SIRG, who will report quarterly to the KSCP on progress against actions. The update of Action Plans will be undertaken quarterly by the KSCP Business Manager.

Liaison will take place between the SIRG Chair and other Working Groups to agree audit and scrutiny of processes developed and implemented through Individual Agency and Multi-Agency Action Plans.

12. Management Reviews and File Audits

Where the decision of the SIRG is that the case does not meet the criteria for SCR they can make a recommendation to the Chair if the KSCP that a management Review/ Case Audit should be undertaken.

In such circumstances the SIRG should consider Terms of reference for the Review, identify a Chair of the review with appropriate independence and the agencies who should participate in the review using the same standards as applied within the SCR process.

As a matter of routine Management Reviews should be conducted with the rigour of a SCR and Chronologies and Individual Management Reports should be completed to the same exacting standard.

Reporting on the progress and outcome of such reviews will be to the SIRG and any recommendations emerging should be included within SIRG actions plans and monitored accordingly.

13. Accountability and Disclosure

Family:

The SIRG/ MRG will decide:

1. Who is best placed to inform the family of the decision to undertake a SCR or Management Review and at the same time seek the necessary consent and co-operation of the family;
2. The level of involvement of family members including children of suitable age and extended family where their involvement has been significant;
3. Who should inform the family of the outcome of the SCR (Management Review) and provide a copy of the Overview Report / Executive Summary as appropriate.

The KSCP should consider carefully who might have an interest in Reviews - e.g. elected and appointed members of authorities, staff, the public, the media - and what information should be made available to each of these interests.

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 sharing information when criminal proceedings are outstanding, in that access to the contents of information may not be within the control of the KSCP.

It is important to anticipate requests for information and plan in advance how they will be met. For example, a lead agency may take responsibility for debriefing family members, or for responding to media interest about a case in liaison with contributing agencies and professionals. In all cases, an Executive Summary and the Overview Report for SCRs initiated after 10 June 2010, should be made public. For further information please see letter from Tim Loughton to LSCP Chairs. The publication of the Executive Summary needs to be timed in accordance with the conclusion of any related criminal proceedings. The content needs to be suitably anonymised in order to protect the confidentiality of relevant family members and others.

Although KSCP is not a 'responsible authority' under the Freedom of Information Act (2000) any requests made of KSCP under that legislation will be considered by the Chair of KSCP and each request will be treated on its own merits. Where necessary appropriate advice will be taken and liaison with stakeholders will take place.

The KSCP should ensure that OFSTED and the Safeguarding Group, Department for Education (DfE) are fully briefed in advance about the publication of the Executive Summary/Overview Report.

14. Reviewing Institutional Abuse or where there are Multiple Abusers

Where 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 victims 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 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.

15. Learning the 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, as well as to integrate this information with that from other serious case or local reviews;
• Focus recommendations on a small number of key areas, with specific and achievable proposals for change and intended outcomes;
• The KSCP will review and monitor agency Action Plans and put in place a means of auditing action against recommendations and intended outcomes.

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 KSCP 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.

It is the responsibility of the KSCP member organisations to ensure staff and their representatives understand what can be expected in the event of a child death/case review.

KESCP will organise regular multi-agency training events to ensure that the lessons from SCRs both locally and nationally are disseminated to front line staff and their managers. In addition lessons from SCRs will inform the delivery of specialist and single agency training.

16. Learning the Lessons Nationally

Taken together, child death and SCRs should be an important source of information to inform national policy and practice. The DfE is responsible for identifying and disseminating common themes and trends across review reports, and acting on lessons for policy and practice. It is considering how best to collate the findings from the work of the local child death overview teams.

Appendix A - Notification of Incidents to Secretary of State, Safeguarding Group (DfE) and Ofsted

Local authorities should notify Ofsted of serious incidents involving children which:

• Are serious enough that they may lead to a SCR (including "where a child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect" - Working Together paragraph 8.6); or
• Involve a child death and will automatically lead to a SCR ("when a child dies (including death by suicide) and abuse or neglect is known or suspected to be a factor of the child's death" - Working Together paragraph 8.5); or
• Should be brought to the attention of Ofsted and the Government because of concern about professional practice or implications for Government policy; or
• Raise issues about council's professional practice that may need to be considered further in the context of performance assessment; or
• Have attracted or are likely to attract media attention (When considering using this criterion as the primary basis for making a notification, local authorities should consider the level of interest and implications. There is unlikely to be a clear distinction between local and national media and other factors (such as characteristics, may affect the decision). Local authorities should consider whether the details of the incident could prompt approaches to be made to DfE Press Office for Ministerial reaction).

Ofsted's National Business Unit (NBU) is the contact point for notifications and can be reached by telephone 0846 40 40 40. The NBU will be able to support you through the notification process.

In order to send notification forms by post (they should not presently be sent electronically), please address them to: Ofsted, National Business Unit, 3rd floor, Royal Exchange Buildings, St Anne's Square, Manchester, M2 7LA.

As of 21 February 2011, the notification arrangements for SCRs have changed. The Safeguarding Group at the DfE have replaced the role of Government Office in relation to notification arrangements. In order to keep ministers briefed, the Safeguarding Group should be informed of:

• New childcare incidents notified to Ofsted as being serious enough potentially to lead to SCRs and other cases which are receiving significant media attention;
• Decisions to initiate SCRs and information on planned completion dates and plans for publishing Executive Summaries and (for SCRs initiated after 10 June 2010) Overview Reports; and
• Where known, expected dates of court proceedings related to child protection incidents and the outcome of court cases including verdicts and sentencing.

The Safeguarding Group may also seek further ad hoc information from KSCPs. For further information please see letter from Jeanette Pugh to LSCP Chairs, 10 February 2011.

Appendix B - Terms of Reference and Scoping

Appendix C - Independent Management Reviews Good Practice Guide

• Author and credentials identified including the element of independence;
• Report clearly within agreed dates;
• Countersigned by strategic managers.

Thorough, comprehensive chronology highlighting all contacts/ adherence to policy/ procedure and relevance to the terms of reference

• Clear Genogram;
• Terms of Reference clearly stated;
• Starting point should be - 'What were the duties and responsibilities of that agency towards the child/ family?' From that point cover:
  • Were these obligations fulfilled?
  • If not - why not?
  • What can be learnt?
  • Reflect good and poor practice.
• Challenging of own agency practice - comprehensive report section not only stating WHAT happened but WHY it didn't happen HOW could it be prevented from happening again;
• Links to standards and practices of agency;
• Strong analytical section identifying underlying reasons and impact;
• Use of research is encouraged;
• Clear recommendations from Independent Management Review and are achievable;
• Clear learning points reflect good and poor practice;
• Family history & diversity issues need to be clearly considered and discussed;
• Show that the focus on agency intervention was on the child (if not why not?);
• Consider the situation from the child's perspective, seek their views (or explain why not);
• Show how parental factors impacted on the child/ children;
• Conclusions section addresses the TOR.

Recommendations/ action plans should:

• Be robust;
• Be SMART and be reflected in achievable action plans;
• No more than 3-4 per report;
• Reflect the key issues contained within the TOR;
• Be specific and not refer generically to 'training' or 'procedures';
• Be succinct and not wordy;
• Highlight what is going to be done differently.

Appendix D - Overview Reports Good Practice Guide

The author should:

• Be independent;
• Have relevant experience and expertise;
• Have the confidence of the Board and Board members;
• NOT chair any meetings but may be present;
• Comment on the quality and content of the IMRs;
• Ensure the report reflects the TOR and not just quote them;
• Draw on research and findings of previous SCRs.

The Report should include:

• Genogram and family history including race, culture, language, religion & disability issues discussed and addressed;
• Demonstration of the ways in which the parents/ wider family have been involved (where this is possible and does not impact on other processes);
• Good critique of Independent Management Reviews and their contribution to learning the lessons;
• Draws together findings/ issues contained in Independent Management Reviews;
• Logical and evidence based;
• Detailed analysis supported by research;
• Analysis to include What went wrong and whether other actions would have resulted in different outcomes (use of hindsight);
• Clearly identifies good and poor practice;
• Lessons to be learnt address the TOR;
• Recommendations are explicit and capture key issues;
• Conclusions section addresses the TOR.

Recommendations/ action plans should:

• Be robust;
• Be SMART and be reflected in achievable action plans;
• No more than 3-4 per report;
• Reflect the key issues contained within the TOR;
• Be specific and not refer generically to 'training' or 'procedures';
• Be succinct and not wordy;
• Highlight what is going to be done differently.

Appendix E - SCR Process Flowchart

Click here to view flowchart

Appendix F - Referral Form for Serious Incident Review Group Consideration of a Case Review

Click here to view form