8.1 Serious Case Review Procedure

The Local Safeguarding Children Board (LSCB) will always undertake a Serious Case Review (SCR) when a child dies (including a death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the child's death. This is irrespective of whether the local authority Children's Social Work Services are or have been involved with the child or family. These SCR's should include situations where:

• A child has been killed by a parent, carer or close relative with a mental illness, or who is known to misuse substances or to perpetrate domestic abuse,
• A child dies in custody, either in police custody, on remand or following sentencing, in a Youth Offending Institution (YOI) or a Secure Training Centre (STC), or
• A child was detained under the Mental Health Act 2005.

The LSCB will also always consider whether to undertake a SCR where:

• A child has sustained a potentially life-threatening injury through abuse or neglect; or
• A child has sustained serious and permanent impairment of physical health and/or development through abuse or 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 undertaken under the Domestic Violence Act 2004 or
• A child has been seriously harmed following a violent assault perpetrated by another child or an adult;

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

The purpose of the Serious Case Review (SCR) will be 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 upon, and what is expected to change as a result; and
• Improve intra- and inter-agency working and better safeguard and promote the welfare of children.

In deciding whether to undertake a SCR, a 'yes' answer to several of these questions is likely to indicate that a SCR will yield useful lessons:

• Was there clear evidence of a child having suffered, or been likely to suffer, Significant Harm, which was:
  • Not recognised by organisations or professionals 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, children's or family centre, YOI, STC, immigration removal centre, mother and baby unit in a prison, 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 as Asylum Seekers or temporary workers?
• Did the child suffer harm during an Unauthorised Absence from an institution, or having run away from home or other care setting?
• Does one or more agency or professional consider that its concerns about a child's welfare 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 operation of LSCB procedures, which go beyond the handling of this case?
• Was the child subject to a Child Protection Plan at the time of the incident or had the child been previously subject to a Child Protection 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 upon?
• Are there any indications that the circumstances of the case may have national implications for systems or processes, or that it is in the public interest to undertake a SCR?

In order to maximise the quality of learning, the child's daily life experiences and an understanding of his or her welfare, wishes and feelings must be central to the SCR. This perspective should inform the scope and terms of reference of the SCR and be addressed at all stages of the process.

Relevant issues include:

• What appear to be the most important issues to address in identifying the learning from this specific case? How can the relevant information best be obtained and analysed, including, for instance, information on the mental health of relevant adults?
• When should the SCR start, and by what date should it be completed, bearing in mind the timescales for completion set out below? Are there any relevant court cases or investigations pending which could influence progress or the timing of the publication of the Executive Summary?
• Over what time period should events in the child's life be reviewed i.e. how far back should enquiries extend, and what is the cut off point? What family history/background information will help better to understand the recent past and the present?
• How should the child (where the review does not involve a death), surviving siblings or other family members contribute to the SCR and who should be responsible for facilitating their involvement? How will they be involved and contribute throughout the overall process?
• Are there any specific considerations around ethnicity, religion, diversity or equalities issues that may require special consideration?
• Did the family's immigration status have an impact on the child/children or on the parents' capacities to meet their needs?
• Which organisations and professionals should be asked to submit reports or otherwise contribute to the SCR, including where appropriate, for example, the proprietor of an independent school or a playgroup leader)?
• Who will make the link with relevant interests outside the main statutory organisations, e.g. independent professionals, independent schools, independent health care providers or voluntary organisations?
• Is there a need to involve organisations/professionals working in other LSCB areas, and what should be the respective roles and responsibilities of the different LSCB's with an interest?
• Will the LSCB need to obtain independent legal advice about any aspect of the proposed SCR?
• Who should be appointed as the independent author for the Overview Report (bearing in mind that this person should not be the Chair of the LSCB or the Serious Case Review Panel
• Might it help the Serious Case Review Panel to bring in an outside expert at any stage, to help understand crucial aspects of the case?
• Will the case give rise to other parallel investigations of practice, for example, into the health or adult social care provided or multi-disciplinary suicide reviews, a domestic homicide review where a parent has been killed, a Prisons and Probation Ombudsman (PPO) Fatal Incidents Investigation where the child has died in a custodial setting or a Serious Further Offence or MAPPA Serious Case Review process where offenders are charged with serious further offences whilst subject to statutory supervision? And if so, how can a co-ordinated or jointly commissioned review process address all the relevant questions that need to be asked in the most effective way and with minimal delay? Arrangements should be agreed locally on how a NHS Serious Untoward Incident investigation into the provision of healthcare should be co-ordinated with a SCR
• How will the SCR terms of reference and processes fit in with those for other types of reviews - for example, for homicide, mental health or prisons?
• How should the review process take account of a coroner's inquiry, any criminal investigations (if relevant), family or other civil court proceedings related to the case? How will it be best to liaise with the coroner (See the Ministry of Justice website) and/or the Crown Prosecution Service (CPS) and to ensure that relevant information can be shared without incurring significant delay in the review process?
• How should the review process take account of relevant lessons learned from research (including the biennial Overview Reports of SCR's) and from SCR's which have been undertaken by the LSCB?
• How should any family, public and media interest be managed before, during and after the SCR? In particular, how should surviving children (where appropriate given their age and understanding) and family members be informed of the findings of the SCR?

The role of the Local Authority Legal Adviser to the Serious Case Review Panel (SCRP) may include:

• Liaison with other agencies in particular the Police and Crown Prosecution Service to ensure that the Serious Case Review (SCR) process does not conflict with actual or potential prosecutions or appeals.
• Analysis of new case law/statute affecting the SCR process.
• Ad hoc advice to the LSCB, Chair of the SCRP and to the author of the Overview Report.

• Introduction
  • Summarise the circumstances which led to a review being undertaken in this case
  • State terms of reference of review
  • Record the methodology used including the documents reviewed, and whether the information was provided in an interview or through written evidence
  • List agencies or types of contributors to review and the nature of their contributions (for example, IMR by local authority, report through the PCT as commissioner from adult mental health service). List the names and roles/ positions/job titles of the LSCB Chair, SCR Panel Chair, the author of the Overview Report and the job titles and employing organisations of all the SCR Panel members
  • List external investigations, if any, that are being conducted (for example the PPO investigation following the death of a child in custody or a mental health inquiry)
• The Facts
  • Prepare an anonymised genogram showing membership of family, extended family and household
  • Compile an integrated chronology of involvement with the child and family on the part of all relevant organisations, professionals and others who have contributed to the review process. Note specifically in the chronology each occasion on which the child was seen, if the child was seen alone and whether the child's view and wishes were sought or expressed
  • Consider explicitly any relevant ethnic, cultural or other equalities issues and whether these are relevant to the behaviours and approach taken by the organisations and professionals involved
  • Summarise the relevant information that was known to the agencies and professionals involved about the parents/carers, any perpetrator and the home circumstances of the children
• Analysis
  • This part of the Overview Report 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. It is important that this is objective and open, being clear where systems could improve. The analysis section is also where any examples of good practice should be highlighted. The findings from this SCR should be considered alongside learning from previous SCR's undertaken by the LSCB and findings from relevant research.
• Conclusions and Recommendations
  • This part of the report should summarise what lessons are to be drawn from the case, and how they should be translated into recommendations for action, and to what timescales. Recommendations should include, but should not simply be limited to, the recommendations made in individual management review reports. 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 and the information sent to the relevant government department.

Serious Case Review Panel (SCRP) responsibilities for the Overview Report

The SCRP should:

• Ensure that it actively manages the Review process, seeking legal advice as necessary, so that the findings from other relevant processes such as care or criminal proceedings, an inquest or inquiry/investigation are incorporated into the Overview Report;
• Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the Overview Report;
• Ensure that the Overview Report is of a high standard and is written in accordance with this guidance;
• Ensure that the Overview Report is suitably anonymised and information appropriately redacted so that it is in a form suitable for publication
• Commission and agree the content of the Executive Summary for publication, ensuring that it accurately represents the full SCR, includes the action plan in full and is fully anonymised apart from including the names of the SCRP Chair and the Overview Report author and the job titles and the employing organisations of all the SCRP members;
• Translate recommendations into an action plan that should be signed up to by the senior manager in each of the organisations that will be involved in implementing the action plan. The plan should set out who will do what, by when, with what intended outcome and how success will be measured. The plan should set out the means by which improvements in practice/systems will be monitored and reviewed;
• Clarify to whom in which agencies or organisations the Overview Report , Executive Summary and the action plan of the SCR should be made available to support implementation of the recommendations and the learning of the lessons; and
• Make arrangements to provide feedback and debriefing to the child (if surviving) and family members/carers of the subject child as appropriate, following completion of the Overview Report and Executive Summary

LSCB action on receiving the Overview Report

The LSCB should approve the final SCR and:

• Provide an anonymised copy of the IMR's, Overview Report, Executive Summary and the individual and multi-agency action plans and chronologies to Ofsted, the SHA and the Department for Education. All personal information relating to children, family members and professionals involved in the case (with the exception of the names of the LSCB and SCRP chairs and the Overview Report author) should be anonymised in all the SCR documentation submitted to Ofsted. If the child died in a custodial setting, copies of the anonymised SCR should be made available to the YJB and copies of the executive summary should be provided to the Prisons and Probation Ombudsman;
• Make arrangements to provide feedback and debriefing to staff and the media as appropriate;
• Publish the Overview Report once the SCR has been completed;
• Disseminate the executive summary and key findings to relevant interested parties;
• Publish the SCR executive summary once the SCR has been completed
• Implement those actions for which the LSCB has lead responsibility and monitor the timely implementation of the SCR action plan;
• On receipt of the evaluation letter from Ofsted, take action as necessary to amend the action plan/  the SCR report/  the SCR executive summary if they have been published before receiving Ofsted's feedback; and
• Formally conclude the review process when the action plan has been implemented and inform the Department for Education of this decision.

Executive Summaries should be produced according to the following outline format, although as with IMR's and Overview Reports, the precise format will depend on the features of the case.

Format of Serious Case Review executive summary

Introduction

• Summarise the circumstances that led to a SCR being undertaken in this case and the process followed by the review.
• List the names of the LSCB Chair, SCR Panel Chair and the author of the Overview Report, and the job titles and employing organisations of all SCR Panel members.
• Note the parallel processes, where relevant, that are being or have been conducted and how they have interrelated with the processes followed by the review (for example, criminal proceedings, PPO investigation following the death of a child in custody, or independent investigation of adverse events in mental health services).
• Note the extent to which the family (and the child, where he or she has been seriously harmed) have been involved in the review.

The facts/summary of events

• Summarise the key facts of the case and the sequence of events. This should be an accurate précis of circumstances of the child and their family and of the chronology of the involvement of the relevant agencies. The narrative should be consistent with the detailed chronology in the full overview report.
• Care should however be taken to ensure that the summary is appropriately anonymised and sensitive to the child and family in respect of information that will be available in the public domain.

Key issues or themes arising from the case

• Summarise the key issues or themes arising from the analysis in the overview report, and highlight the key decisions taken in respect of the child and their family and the opportunities for early intervention where they existed. With hindsight could or should different decisions or actions have been taken at the time?

Priorities for learning and change

• Describe clearly the conclusions and lessons learned from the review, both for individual agencies and for inter-agency working through the LSCB and the Children's Trust Board, ensuring these are in the context of the issues or themes that arose from the case.
• Identify examples of good practice as well as being clear where systems should improve.

Recommendations and action plan

• Reproduce the recommendations and action plan from the full SCR.
• The action plan should highlight which recommendations are relevant to which agencies, the agency/ies responsible for taking forward specific recommendations, how action will be monitored and by whom. It should also set out the progress that has already been made in implementing or completing recommendations and plans to evaluate the impact of these changes.

Once accepted by the LSCB, the Serious Case Review documents will be submitted to Ofsted and the Department for Education within 6 months of the decision to initiate the SCR.

See also The Serious Case Review Flowchart.

In making decisions about this, the LSCB will balance the following considerations:

• 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; and
• Constraints in sharing information when criminal proceedings are ongoing in that access to the contents of information may not be within the control of the LSCB.
  
  See also Paragraph 11.4 in relation to access to records and information sharing.

The LSCB will promote processes which ensure that maximum benefit is gained from the Serious Case Review process and lessons from it are learned. The following will help to achieve this:

• As far as possible, conduct the review in such a way that the process is a learning exercise in itself for all those who have been involved in the case;
• Consider what type and level of information needs to be disseminated, how and to whom, in the light of a SCR. 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;
• Incorporate the learning into local training programme's;
• Focus recommendations on a small number of key areas, with Specific, Measurable, Achievable, Relevant and Timely proposals for change and intended outcomes.

In addition:

• The LSCB should put in place a means of monitoring and auditing the actions of all agencies against recommendations and intended outcomes; and
• PCT's should seek feedback from SHA's who should use it to inform their performance management role, and the CQC may use the findings of SCR's to inform its processes for regulating NHS and independent sector provider organisations. PCT's will monitor the implementation of the recommendations by provider organisations.

Day to day good practice can help ensure that Serious Case 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 disciplines and 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/serious case review.

Information held and/or gathered by agencies for the purpose of a Serious Case Review may fall within one or more of the following exemptions:

• Investigations and proceedings conducted by public authorities (e.g. a criminal investigation).
• Court records.
• Health and safety (disclosure would be likely to endanger the physical/mental health/ safety of an individual)
• Personal data *
• Information provided in confidence (disclosure would constitute a breach of confidence).

Requests by individuals involved with the Case Review for information concerning themselves should be dealt with in accordance with the Data Protection Act 1998.