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8.2 Serious Case Review Guidance

SCOPE OF THIS CHAPTER

This guidance lays out the process to be followed when undertaking a Serious Case Review.

This chapter was introduced into the manual in February 2015.

NOTE:

New arrangements are in place relating to the notification of serious child safeguarding incidents. From the 29th June 2018, Local authorities have a duty to notify serious incidents involving children where they know or suspect that a child has been abused or neglected and:

  1. The child dies or is seriously harmed in the local authority’s area; or
  2. While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

To the national Child Safeguarding Practice Review Panel (the Panel). These notifications should be made within five working days of the local authority becoming aware of the incident.

More details about the arrangements with the panel and the process to follow can be found in Edward Timpson (Chair of the Panel) letter titled The Child Safeguarding Practice Review Panel: Working Together 2018.

Local authorities should continue to use Ofsted’s current online notification system to notify the Panel until a new system for the Panel goes live later in 2018. Notifications made through this route will go to the Panel, Ofsted and the DfE.

The local authority should also report the incident, within the same five working days, to the relevant LSCP, or to the new local safeguarding partners when they become established.

The Panel will consider whether to commission national reviews and also consider LSCPs’ decisions on the initiation and publication of SCRs. LSCPs should, therefore, now send all information about decisions not to initiate or to publish an SCR to the new Panel at Mailbox.NationalReviewPanel@education.gov.uk.

This should include decisions relating to all child safeguarding incidents notified to Ofsted and DfE before July 2018 but where no further information on the case has been sent to the national panel of independent experts.

Chapter 4 of Working Together to Safeguard Children sets out the new arrangements for a learning system to replace the serious case review process. However the plan is for the Child Safeguarding Practice Review Panel to issue further guidance so amendments to this chapter will take place once the additional guidance is available.


Contents

  1. The Purpose of Serious Case Reviews
  2. Scoping a Serious Case Review
  3. Process for Appointing an Independent Overview Chair and Overview Author
  4. SCR Panel Role and Responsibilities
  5. Agency Notification
  6. Involving Families
  7. Timescales
  8. Impact of Freedom of Information Act
  9. Authors of Individual Management Reviews
  10. Individual Management Reviews (IMR’s)
  11. IMR Authors Interviewing Staff and Staff Care
  12. Presentations of Individual Management Reviews to the SCRP
  13. Writing the Overview Report
  14. Finalisation and Adoption of the Serious Case Review Report
  15. Retention of Papers
  16. Communication Strategy
  17. Implementation and Monitoring of the Action Plan
  18. Learning Lessons on Process

    Appendix 1: Consideration of Case for Serious Case Review - Referral Form

    Appendix 2: Letter Advising of a Serious Case Review Request to LSCP Agency Members

    Appendix 3: Leaflet for Parents

    Appendix 4: Letter of Invitation to Authors Briefing

    Appendix 5: Letter for Commissioning Individual Management Reviews

    Appendix 6: Standard Format for an Individual Management Review

    Appendix 7: Chronology Template

    Appendix 8: Interview Format

    Appendix 9: Overview Report Communications Plan

    Appendix 10: Letter of Invitation to a Practitioners De-Briefing

    Appendix 11: Flowchart - Performance Management Plan And Timescales

    Appendix 12: Ofsted Descriptors

    Appendix 13: Action Plan Template

    Appendix 14: IMR Author Guide

    Appendix 15: Guidance on Drawing a Genogram

    Appendix 16: Competence Framework for Serious Case Review Independent Authors and Serious Case Review Independent Chairpersons


1. The Purpose of Serious Case Reviews

A Serious Case Review should be conducted where a child has died or been seriously injured as a result of abuse or Neglect or suspected abuse or neglect. 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;
  • To 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; and
  • To improve intra-and inter-agency working and better safeguard and promote the welfare of children.

Serious Case Reviews are not inquiries into how a child died or was seriously harmed, or into who is culpable. These are matters for coroners and criminal courts, respectively, to determine as appropriate

In order to maximise learning, the child’s experiences and perspective should be at the centre of the Serious Case Review.

1.1 When should the Local Safeguarding Children Board undertake a serious case review?

When a child dies, (including by suicide) or is seriously harmed and abuse or neglect are known or suspected to be a factor, LSCP organisations should immediately consider:

  • Are there other children at risk of harm who require safeguarding?
  • Are there any lessons to be learned about the ways in which they work individually and together to safeguard and promote the welfare of children?

Consequently, when a child dies in such circumstances, the LSCP will always conduct a Serious Case Review into the involvement of organisations and professionals with the child and family. These Serious Case Reviews should include situations where a child has been killed by a parent, carer or close relative with a mental illness, known to misuse substances or to perpetrate Domestic Abuse. In addition, a Serious Case Review should always be carried out when a child dies in custody, whether in police custody, on remand or following sentencing, in a Youth Offending Institution (YOI) or a Secure Training Centre (STC), or where the child was detained under the Mental Health Act 2005.

The LSCP will always consider conducting a Serious Case Review whenever a child has been seriously harmed in the following situations:

  • A child sustains a potentially life-threatening injury or serious and permanent impairment or physical and/or mental health and development through abuse or neglect; or
  • A child has been seriously harmed as a result of being subjected to Sexual Abuse;
  • A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Crime and Victims 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 worked together to safeguard and promote the welfare of children. This includes inter-agency and/or inter-disciplinary working.

1.2 Who can make a referral for a serious case review and which LSCP has lead responsibility?

Any professional may refer a case if it is believed there are lessons to be learned. In Solihull such referrals should be made to the LSCP Chairperson. See Appendix 1: Consideration of Case for Serious Case Review - Referral Form. The LSCP Chairperson will convene a Serious Case Review Panel who will in turn advise if the threshold for a Serious Case Review is met as well to recommend the scope and terms of reference for the review.

Where partner agencies of more than one LSCP have known about or have had contact with the child, the LSCP for the area in which the child is or was ordinarily resident should take lead responsibility for conducting the SCR. Any other LSCPs that have an interest or involvement in the case should co-operate as partners in jointly planning and undertaking the SCR. In the case of a looked after child, the local authority looking after the child should exercise lead responsibility for conducting the SCR, again involving other LSCPs with an interest or involvement.

1.3 How is a serious case review decided when a child has not died?

To decide if an SCR is appropriate a number of questions can be asked including:

  • Was there evidence of harm that was not recognised or not acted upon appropriately or not shared between organisations?
  • Was the child abused or neglected in an institutional setting, or abused while being looked after by the local authority?
  • Did the child suffer harm after going missing, or while missing from an institution?
  • Was the child a member of a family that has recently moved to the UK, for example as Asylum Seekers or temporary workers;
  • Does one or more agency or professional consider its concerns were not taken seriously or acted upon appropriately?
  • Had the child been subject to a safeguarding or Child Protection Plan?
  • Are there implications for several agencies or indication that procedures have failed, not been understood or not acted upon appropriately?
  • Are there indications that the case may have national implications or that it is in the public interest to undertake a SCR?

1.4 Instigating and conducting a serious case review

Does the case meet serious case review criteria?

If the SCR criteria are not met, it may still be valuable to conduct individual management reviews or a small-scale audit of the individual case that gives rise to concern. The Chair of the LSCP is advised by the Serious Case Review Panel but is ultimately responsible for deciding whether or not to conduct a Serious Case Review.

How is the scope of the review determined?

The SCR Panel comprising at least of representatives from local authority children’s social care, health, education and the police will decide the scope and terms of reference of the review and will appoint an independent author for the overview report and an independent Chair for the Panel. Scoping the review will help the panel plan when the review will start and finish. The scope of the review is determined by:

  • The period of time and the extent of the family history to be reviewed;
  • Who/which agencies should contribute to the review and how family members will contribute to the review and consideration should be given as to whether any relevant information is available via social networking sites and / or other forms of digital technology;
  • Parallel investigations (e.g. homicide, criminal, coroner’s inquest);
  • The need to consider needs and issues arising from the ethnic, cultural, linguistic and religious background of the child and family, and those relating to the disability of the child and/ or other parties;
  • Decisions to involve other LSCPs and non-statutory organisations;
  • The need to take account of lessons learnt from research and from other serious case reviews;
  • Managing the public, the family and media interest - before, during, and after the review and whether the LSCP will need legal advice.

The LSCP Chair should ensure that the terms of reference address the key issues and is responsible for approving them.

NB. Sometimes SCR terms of reference and/or the status of the review will need revising as new information emerges - e.g. the outcome of a coroner’s court enquiry may find that a child’s death was accidental, and abuse or neglect were not factors. In such cases the decision may be that individual agency management reviews are more appropriate than a serious case review.

1.5 Timing and summary of the process

Every review will be different but lessons should always be learned and acted upon as quickly as possible without necessarily waiting for the SCR to be completed. Once it is known that a case is being considered for review, each organisation should secure paper and electronic records relating to the case and guard against loss or interference. The timetable set out below shows how the process is conducted from the point at which the LSCP becomes aware a review needs to be considered.

First Week

  • The referral is received and Ofsted and Department of Education* are notified by LSCP Administrator of the incident;
  • The Serious Case Review Panel is convened to consider the facts of the case and recommend if the SCR criteria are met;
  • Agency records are secured and practitioners are informed of the death/incident relating to a child on their caseloads;
  • An immediate Multi-Agency media strategy may be required and agreed dependent on the nature of the case, media interest and the public response.

Second and Third Weeks

  • The Chair of the LSCP is advised by the SCR Panel and decides if the criteria are met and whether to invoke a Serious Case Review;
  • Ofsted and Department of Education** are notified of this decision;
  • Agencies are notified of the decision and instructed to ensure that records have been secured;
  • Independent Chair and Independent Author appointed and Panel identified;
  • Scoping Meetings to establish Terms of Reference.

* Mailbox.CPOD@education.gov.uk
** enquiries@ofsted.gov.uk

By the end of the Fourth Week

  • Letters to all agencies sharing Terms of Reference and requesting that IMR authors are identified; and that they begin to prepare their work on chronologies and IMRs;
  • Agencies to keep practitioners updated on the decision and procedures;
  • Family/victims notified of SCR process.

Fifth and Sixth Weeks

  • Any media/publicity arrangements that are required are put in place;
  • IMR authors briefing;
  • IMR authors begin to prepare the IMRs and chronologies via file reading, staff interviews, etc.

Over the next four months

  • The Panel considers individual management reports, merges the chronologies; involves the child’s family; comments on drafts of the Overview Report; and makes recommendations for future practice, training, management and resources and produces a draft Action Plan;
  • A draft of the Overview Report and Action Plan is shared with agency representatives on the SCRP.

In the last month

(N.B. the Serious Case Review must be completed within 6 months from the date of the decision to proceed)

  • The LSCP approves the final SCR that is, the IMR reports, the Overview Report, the Executive Summary and the Action Plans (single and multi agency) and agrees how the report will be made public. At this stage LSCP agencies should agree on the timetabling for implementation, monitoring and audit of Action plans;
  • The SCR is submitted to Ofsted, the SHA and Department of Education.

Reviews should ideally be completed within six months from the date of the decision to proceed unless an alternative timescale is agreed by the LSCP.

1.6 Will there be delays due to criminal proceedings?

In some cases, criminal proceedings may follow the death or serious injury of a child. The Chair of the SCR Panel should discuss with the relevant criminal justice agencies such as the police and the CPS, at an early stage, how the review process should take account of such proceedings.

The Department of Education* should also be advised where known, of expected dates of court proceedings related to child protection incidents and the outcomes of court cases including verdicts and sentencing.

1.7 Who should conduct reviews and who should be involved?

The initial scoping will determine which agencies or individuals should contribute to the review. As new information emerges, for instance through ongoing or related criminal proceedings, the original scoping of contributors may need to be revised. Each relevant service should undertake a separate management review of its involvement with the child and family. The initial scoping of the review will identify who will contribute reports - including independent professionals, such as GPs. If a child's guardian is to contribute, the courts must first waive the legal duties of confidentiality. Designated safeguarding health professionals, on behalf of the PCT(s) as commissioners, should review and evaluate the practice of all involved health professionals, including GPs and providers commissioned by the PCT area. The designated professionals should produce an integrated health chronology and a health overview report focusing on how health organisations have integrated together. The health overview report will constitute the IMR for the PCT as commissioners.

1.8 Data security

In all cases and at all stages in the SCR process from the first notification to Ofsted of a serious incident to the completion of the final SCR report, information relating to children, family members and professionals involved in the case (with the exception of the LSCP Chair, SCR Panel Chair and the overview report author) should be anonymised by the LSCP before being submitted to any external organisation or body (including Ofsted, the Department of Education) and prior to being made a public document.

In order to promote compliance with Data Protection Legislation, the LSCP will communicate with agencies via a secure email address. Agencies are expected to also be able to communicate with the LSCP via a secure email address. In the absence of a secure email address, the LSCP and agencies involved in the SCR will communicate via password protected emails ensuring any data is anonymised. Agencies can also hand deliver completed IMR’s to the LSCP Administrator via a data storage mechanism e.g. Memory stick.

The process of conducting an IMR requires access to records relevant to the child such as those from the health bodies. The public interest served by the SCR process warrants full disclosure of all relevant information within the child’s own records. In some circumstances the person conducting the IMR may require access to information about third parties (for example, members of the child’s immediate family or carers) that is either contained within the child’s health records or in the health records of another person. While in most cases there will be a public interest in disclosing this information, the record holder(s) should ensure that any information they disclose about a third party is both necessary and proportionate. All disclosures of information about third parties need to be considered on a case by case basis, and the reasoning for either disclosure or non-disclosure should be fully documented. This applies to all records of NHS-commissioned care, whether provided under NHS or in the independent or voluntary sector.


2. Scoping a Serious Case Review

The following matters must be jointly considered by the SCR Panel and agreed by the LSCP Chair in the event of a Serious Case Review.

  • 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 would help better to understand the recent past and the present?
  • How should the child (where the review does not involve a death), surviving siblings, parents 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 diversity or equality issues that need to be address including; ethnicity, disability, religion and impact of poverty?
  • 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 playgroup leader?
  • Who will make the link with relevant interests outside the main statutory organisations, for example independent professionals, independent schools, independent healthcare providers or voluntary organisations?
  • Is there a need to involve organisations/professionals working in their LSCP areas and what should be the respective roles and responsibilities of the different LSCPs with an interest?
  • Will the LSCP 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 and as the Independent Chair of the SCR Panel;
  • Might it help the SCR 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 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 (SFO) or MAPPA Serious Case Review (MSCR) 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 provisions of healthcare should be co-ordinated with a SCR;
  • 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 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 SCRs) and from SCRs which have been undertaken by the LSCP?
  • How should any family and public 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?
  • How should any members of staff be interviewed?
  • Are there implications in respect of disciplinary proceedings, is an HR perspective required and are there implications for staff being interviewed?
  • How should any media interest be handled, before, during and after the review? In cases where there is likely to be media interest it is particularly important to have a strong media strategy in place that is understood and agreed by both the LSCP and the respective Press Offices. A meeting of the Chair and Press Officers and legal representatives should be arranged at an early stage in the review and then towards the conclusion of the review - or at any other point where it seems sensible to do so, e.g. the conclusion of a trial, a Coroner’s inquest etc.

Some of these issues may need to be revisited as the review progresses and new information emerges.

2.1 Agreeing Terms of Reference

Better outcomes can be achieved if all the Individual Management Reviews address the same questions and issues, pertinent to the Case Review being undertaken. These should be formulated as case-specific Terms of Reference.

Time spent on this part of the process is crucial and will affect the quality of Individual Management Reviews and ultimately, lessons arising from the Overview Report. The development of Terms of Reference is time intensive and may take the SCRP two or three meetings to achieve.

Initial Terms of Reference drawn up following discussion within the SCRP need to form part of a consultative process, during which representatives on the SCRP share them with the relevant officers within their own organisations.

As the Terms of Reference go through several re-writes, a date on each draft version is vital (use of footer).

The Terms of Reference are finalised once the LSCP Chairperson has approved them.

2.2 Contacting OFSTED/Department of Education

Local Authorities should notify Ofsted and the Department of Education of serious incidents involving children which:

  • Fall within the criteria under which a LSCP should always conduct a serious case review;
  • Fall within the criteria under which a LSCP should consider conducting a serious case review as well as;
  • Other cases which have attracted or are likely to attract significant media attention.

Ofsted should also be notified of Serious Incidents involving children because of concern about professional practice or implications for Government policy; or that raise issues about a council’s professional practice that may need to be considered further in the context of performance assessment;

Ofsted’s National Business Unit (NBU) will be the contact point for notifications and can be reached by telephone 0300 123 1231. The NBU will support Local Authorities and/or LSCP’s through the notification process.

Notification forms returned by post should be sent to: Ofsted, National Business Unit, Piccadilly Gate, Store Street, Manchester, M1 2WD.

The Department of Education should also be informed of the decision to initiate SCRs, dates of SCR completion and submission to Ofsted for evaluation; plans for publication of executive summaries and (where appropriate) overview reports; and actual publication dates. Paragraph 1.7.2 also sets out the information required by the Department of Education in respect of court proceedings.


3. Process for Appointing an Independent Overview Chair and Overview Author

The Chair of the SCR Panel should not be a member of the LSCP(s) involved in the SCR, an employee of any of the agencies involved in the SCR or the overview report author. The SCR Panel Chair can be someone from another LSCP which is not involved in the SCR or from an agency which is not involved in the case. The overview report author should not be the chair of the LSCP or the SCR Panel.

The Chair of the LSCP has responsibility for ensuring suitable candidates and the LSCP has agreed a set of requirements that will be used to commission Independent Authors and SCR Panel Chairpersons. A copy of the requirements can be found at Appendix 16: Competence Framework for Serious Case Review Independent Authors and Serious Case Review Independent Chairpersons.

Confirmation will also be sought that the individual has:

  • Professional indemnity cover;
  • Access to supervision; and
  • Operates to manage information in accordance with Data Protection legislation.

Once the appointments are agreed, contracts outlining terms and conditions will be sent to the Overview Author and Independent Chair. The contracts will specify the tasks required e.g. writing of Overview Report, production of Executive Summary and Chairing the Panel. Sample contracts can be found at Appendix 16: Competence Framework for Serious Case Review Independent Authors and Serious Case Review Independent Chairpersons.


4. SCR Panel Role and Responsibilities

The Serious Case Review Panel (SCRP) will have the following Responsibilities:

  • Draft Terms of Reference for each SCR which will be subject to consultation and agreed by the Chair of LSCP;
  • Commission Individual Management Reviews and draw up clear Terms of Reference including timescales;
  • Give adequate consideration to the impact of parallel processes e.g. criminal investigations, disciplinary procedures and advise the LSCP accordingly;
  • Ensure that the identified Chief Executive Officers in each organisation are aware of the IMR/SCR and that the Individual Management Review is signed off by the agency;
  • Ensure the quality of the IMR’s against the OFSTED descriptors; if necessary this may require IMR’s to be re-worked or revised; and where there are disputes, resolution may need to be at a senior level;
  • SCRP will consider the wider issues of accountability and publication. The panel will identify who might have an interest in SCR’s and consider what information should be made available to each of these interested parties. The advice and guidance of the associate members of the SCRP: Communications staff, Legal Services, Information and Clinical Governance staff will be of value in these discussions;
  • SCRP will ensure that an Overview Report, with recommendations for action and an action plan are produced which bring together the information and analysis contained in IMR’s together with reports commissioned from any other relevant parties, using an outline that clearly reflects both guidance in Working Together and the agreed Terms of Reference;
  • Ensure the timely production of an anonymised Executive Summary;
  • Develop and co-ordinate a communications strategy to ensure that the lessons learnt from SCR’s can be shared and made public.

The Review Panel will also have reporting responsibilities and will fulfil these by:

  • Chair of the LSCP identifying a member of SCRP who will have responsibility to notify OFSTED and other inspectorates when a decision is made to undertake a SCR;
  • Identified member of SCRP to provide monthly update of SCR’s to LSCP Chair including progress and planned dates for completion;
  • Identified member of SCRP to ensure that LSCP and Chief Executive Officers of relevant organisations are briefed about the work of the SCRP on a regular basis;
  • Identified member of SCRP to consult about revised timetable with Ofsted where SCR’s cannot be completed within 6 months.


5. Agency Notification

Once a referral for a SCR has been received, the LSCP chair will, within 1 working day, send a copy of the referral form, with a standard letter (See Appendix 2: Letter Advising of a Serious Case Review Request to LSCP Agency Members) to all core members of the LSCP and to any other agencies where there is any indication that they may been involved in the case. This requires agencies to seal their files and to confirm if they have had any contact with the child or family and briefly outline their knowledge of the case.

Letter SCR Request.v1/2010 should be copied to Chief Officers of LSCP Agencies and to Chief Officers of other organisations where there is knowledge to indicate that they may have had involvement. This includes agencies out of the country.

PCT commissioners should ensure their Strategic Health Authority (SHA) and the Care Quality Commission (CQC) are notified of the decision of the LSCP Chairperson as to whether a Serious Case Review should be carried out. The police should also notify Her Majesty’s Inspectorate of Constabulary (HMIC) and similarly Her Majesty's Prison and Probation Service should notify Her Majesty’s Inspectorate of Prisons (HMIP) and Her Majesty’s Inspectorate of Probation (HMI Probation).


6. Involving Families

Working Together, urges LSCP’s to consider the degree to which they involve families in Serious Case Reviews, and who should be responsible to facilitate this. Each case is unique and it is therefore important that careful consideration is given to the best means of notifying families.

Involvement can range from formal notification only, to inviting them to share their views with the Overview Author in writing or through an interview. These questions will form part of the discussions when the SCRP is drawing up its Terms of Reference for the particular Serious Case Review.

Normally families (this is usually family members who have played a significant role in the child’s life, such as parent(s) and grandparent(s)) should be notified that the Serious Case Review is taking place. This is best done by a short letter enclosing an information brochure as detailed in Appendix 3: Leaflet for Parents. This letter should be sent either directly to the family members or via their solicitor(s) or hand-delivered by someone with a good rapport with the family, as seems most appropriate given the particular circumstances. The timing of such notifications is crucial particularly where there are ongoing Police investigations. Under these circumstances, the decision about when to notify needs to take place within the SCRP, with the Police representative present.

6.1 Involving victims

Each case is unique and it is therefore important that careful consideration is given to the best means of notifying victims. For example, where the review concerns historical abuse and the child is now a young person or adult, a sensitively handled notification can be a positive experience, allowing some sort of “closure”. This can be achieved through them being informed of the process and helped to understand the issues raised.

Consideration will need to be given as to how the Executive Summary and Overview Report will be shared. It may be appropriate, depending on the age and understanding of the child/adult, for this to be done in person, rather than by letter.

6.2 Staff Care and Supervision

The impact upon workers of being involved in a SCR must be taken seriously by their employing agency and they will have responsibility for ensuring appropriate support is made available to staff. Support should be considered for:-

  1. Practitioners who worked with the child/family;
  2. Frontline Managers responsible for overseeing the service provision;
  3. IMR Authors;
  4. SCR Panel Members.

Supervision should also be used to promote reflective practice or development issues that will need to be addressed via continuing professional development for practitioners or front line managers.

Supervision and management support should be provided to IMR Authors by the employing agency to promote an open and critical review of individual and organisational practice. The IMR should be quality assured by the Senior Officer in the organisation who has commissioned the report and the findings accepted. The Senior Officer will be responsible also for ensuring that the recommendations of both the IMR & where appropriate the Overview Report are acted on.

Supervision and management support should also be provided by the employing agency to SCR Panel Members to promote an objective and open review of learning. Any member of the SCR Panel is able to discuss any concerns re: the work of the SCR with a Senior Officer in their organisation.

As part of the commissioning of the SCRP Chairperson and Independent Overview Report Author, the LSCP should assure itself that these individuals have in place a system to access appropriate professional support so as to enable to deliver their roles effectively.


7. Timescales

Given that the primary purpose of Serious Case Reviews is to contribute to the improvement of inter-agency practice, the SCRP should ensure that lessons are learned and acted upon as quickly as possible.

Working Together to Safeguard Children 2015 states that “within one month” of a case coming to the attention of the LSCP Chair, the decision should have been made by the LSCP Chairperson, as to whether a review should take place.

The Serious Case Review should be completed within a further 6 months unless an alternative timescale is agreed by the LSCP.

The SCRP will ensure a written timeframe/project plan is established to promote compliance with statutory timescales.

7.1 Delay

Sometimes the complexity of a case does not become apparent until the review is in progress. If it emerges that the SCR cannot be completed within six months, the LSCP should revise its timetable. Where an extension beyond the six month timeframe is necessary the LSCP should inform Ofsted of the new completion date and of the reason for the extension.

The SCRP should review progress against the written timeframe/project plan at each meeting and consider any factors that may impact on timescales e.g. parallel investigation. Any deviation from the original written timeframe should be bought to the attention of the LSCP at the earliest opportunity.


8. Impact of Freedom of Information Act

Under the FOIA any person has the right to make a request for information held by a public authority.

The statutory members of the LSCP are subject to the provision of the Act and should have procedures for dealing with requests. Any organisation receiving a Freedom of Information request concerning a Serious Case Review should discuss this with the SCRP Chairperson.

The Act recognises that there are grounds for withholding information and provides a number of exemptions from the right to access; some of which are subject to a Public Interest test.

Information held and/or gathered by agencies for the purpose of a 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 [3];
  • Information provided in confidence (disclosure would constitute a breach of confidence).

Some exemptions are absolute, others are qualified - requiring a balancing exercise to be carried out before a decision is made as to whether to disclose.

Agencies should consult their Information Officer or take legal advice if in any doubt as to whether an exemption applies.

As part of planning for public release of information, the SCRP must consult with the Information Manager of ALL relevant agencies for advice.

NB Requests by an individual involved with the Case Review, for information concerning themselves would be dealt with in accordance with the Data Protection Act.

The Overview Report will be published in full unless there are compelling reasons relating to the welfare of any children/young people directly concerned in the case for this not to happen. The Executive Summary will also be published on the LSCP website once issues raised by Ofsted’s Evaluation of the SCR have been addressed.

SCR Overview Reports contain personal information relating to surviving children, family members and others. The content of the SCR overview report should comply with the requirements of the GDPR and the Data protection Act 2018 when publicised. The LSCP should also be mindful of other restrictions on publication of information, for example Court orders, and should take independent advice if in any doubt on compliance with the law.

8.1 The Criminal Procedure and Investigations Act 1996

This Act gives detailed guidance to Police and Prosecutors regarding disclosure of material to the defence in criminal proceedings.

There are times when a Serious Case Review is being conducted simultaneously with criminal proceedings. On the rare occasion when information comes to light during the Serious Case Review process, that may undermine the prosecution case, the prosecutor has a duty to disclose this to the defence.


9. Authors of Individual Management Reviews

9.1 Criteria for Appointment of IMR Author

Each agency must appoint as its Author a person of sufficient seniority to be able to work at all levels within the agency. The Author must be fair in the way that the views of staff are represented. The Author appointed should be familiar with current child protection practice and is expected to produce an independent and objective report within prescribed timescales in accordance with national guidance.

The Author will not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.

The IMR reports should be quality assured by the senior officer in the organisation which has commissioned the report and when they are satisfied the findings accepted. The senior officer will be responsible also for ensuring that the recommendations of the IMR, and where appropriate the overview report, are acted on.

The Author acts as the representative for an organisation in its interface with the SCRP.

The Author should have unrestricted rights of enquiry and access to staff records and files. It is envisaged that the Author will wish to interview staff who are central to the case. Staff who wish to be interviewed should be offered this opportunity by the Author.

The Author should confirm that the relevant staff within their agency have been informed of the purpose of the Individual Management Review and the process leading to the Serious Case Review.

The Author should ensure that all files relating to the child/family are secured, preferably under lock and key, to ensure information is not lost. The Author should be empowered to demand appropriate security measures are taken. If the case remains open then a full copy of the file should be made for the operational staff and the original file secured. All files should be made available to the Author.

The compilation of the Individual Management Review report will create a significant extra workload. The Author should have his/her workload reviewed in order that he/she is allowed sufficient working time to complete the Individual Management Review report within the strict timescale. The Author should receive appropriate clerical support throughout. It is the agency responsibility to ensure the IMR author receives appropriate supervision and support throughout this process. It is important to recognise that the Author may need to be relieved of all their normal duties for the period the Individual Management Review report takes to compile.

Appropriate extracts of the IMR should be shared with workers involved with the case to ensure the report is factually correct prior to submission.

9.2 Briefing for Authors of Individual Management Reviews

The aim of the Authors Briefing is to reach agreement about how best to achieve a well-integrated and coherent Serious Case Review. In reaching such agreements it is important:

  • To explain the process, what is expected and in particular to emphasise the purpose of the SCR is to learn lessons;
  • To ensure that authors understand the Terms of Reference for the Serious Case Review. It is crucial that the Terms of Reference are meaningful and workable for authors;
  • To agree the format for Individual Management Reviews;
  • To agree that comments made and conclusions reached within all reports need to be evidenced;
  • To raise awareness about the possible need to seek legal advice in the preparation of author’s reports;
  • To stress the importance of meeting agreed deadlines for the submission of their reports to the SCR Panel;
  • To ensure that single agency authors understand the purpose and value of individual presentation of their report to the SCRP.

Additional benefits of the Authors Briefing are:

  • All authors meet each other in a supportive, informal environment;
  • A face-to-face meeting ensures everyone hears the same message. Confusions/questions/queries can be dealt with on the spot;
  • It offers a chance to dispel myths and anxieties about the Serous Case Review process;
  • It enables a timetable to be set for the sequential presentation of reports to the SCRP on an agreed day.

A standard letter of invitation can be found at Appendix 4: Letter of Invitation to Authors Briefing and IMR Authors will also be given a written guide ( Appendix 14: IMR Author Guide) and guidance on producing genograms (Appendix 15: Guidance on Drawing a Genogram).


10. Individual Management Reviews (IMR’s)

Individual Management Reviews will be commissioned using a standard letter (See Appendix 5: Letter for Commissioning Individual Management Reviews) from the organisations involved with the child and family throughout the period of the review agreed as part of the Terms of Reference and will usually include the following organisations:

  • Health;
  • Social Care;
  • Police;
  • Education.

The SCR Panel will provide guidance on what information is required from organisations. Organisations may wish to seek advice from their own legal advisors if they are unclear about information sharing. (e.g. information on parents).

The aim of IMR’s is to look openly and critically at individual and organisational practice, to see whether the case indicates that changes could and should be made, and if so, to identify how those changes will be brought about.

On receipt of Appendix 5: Letter for Commissioning Individual Management Reviews, the Designated LSCP representative of the agency will need to identify the author of the IMR.

The author should be a senior member of staff who has not had any direct involvement with the case. Agencies can decide to appoint an independent author, which would be at their own expense.

As part of the enquiry to enable the IMR to be completed, the author will need to consider the following information:

  • Case Records;
  • Other staff recordings e.g. diaries/pocket book and supervisions;
  • Although the files should be sealed on receipt of Appendix 1: Consideration of Case for Serious Case Review - Referral Form, the author can ask staff to provide complimentary information through a personal statement. However, when completing the review the author should give most weight to contemporaneous recordings and clearly identify retrospective recordings.

IMR’s must be prepared using the agreed format (Appendix 6: Standard Format for an Individual Management Review) and this will include an agreed chronology template (Appendix 7: Chronology Template).


11. IMR Authors Interviewing Staff and Staff Care

All staff who have been involved with the case and their Line Managers must be informed in writing at the earliest possible stage of the nature, scope and timescale of the Serious Case Review by their agency. Staff must also be given an explanation of the rationale for securing their case records. Information should be included in any letter about sources of confidential and independent support that staff may wish to use in connection with their involvement in the SCR, e.g. professional associations, Staff Support Schemes, Council Welfare, Occupational Health, etc.

Good practice indicates that “team” briefings are a very helpful way of conveying information and offering support to the practitioners involved, and also to their colleagues. Similarly, debriefings on completion of an IMR report as well as at the end of the SCR should be instituted in order to confirm and share the learning of the Serious Case Review and any arising implications for practice, training, etc. Throughout the process of the Serious Case Review staff should be updated with the timescale, any media interest, etc.

Staff members providing information and attending interviews about their role and actions in relation to the case should, wherever possible, be given at least 2 weeks notice of the interview and invited to be accompanied by a colleague (though not one who is also directly involved in the review) or their trades union or professional association representative. Each constituent agency of the LSCP will need to determine their own policy on supporters (e.g. if the interviewee requested a lawyer).

Arrangements must be made during these 2 weeks for the interviewee to have access to case files (which have already been secured and are located with the IMR Author) in order for them to refresh their memory of their involvement (which may well extend over many years); or a copy of the file is to be sent to them in order for them to prepare for the interview.

The interview must be conducted in appropriate venues, i.e. confidential and soundproofed, offering hospitality, etc.

Such interviews should be recorded in writing (either in note form or verbatim) and a transcript (or notes) subsequently sent to the interviewee to be approved for accuracy and signature, and a copy sent to them for their records.

The matters likely to be covered in interview include:

  1. Their knowledge of the history of the case, the child(ren) and family prior to the individual's involvement;
  2. Their specific involvement in the case;
  3. Their knowledge of the agency's policy and procedures in relation to child care and child protection;
  4. Their knowledge of child development, identifying injuries in relation to abuse, understanding of the psychological effects of abuse upon a child, direct work techniques, and their role in relation to Child Protection Conferences;
  5. . The methods used to relate to and communicate with other professionals in the case;
  6. The individual's record keeping;
  7. The supervision the individual received;
  8. The individual's feelings about the case, the parent, step-parent or child and how those feelings were dealt with in supervision;
  9. The range of training both within and outside the agency in the last two years;
  10. Whether the agency can learn lessons from the experience;
  11. Looking back, what the individual would now do differently;
  12. What lessons the individual can learn from the experience.

For an Interview format see Appendix 8: Interview Format.


12. Presentations of Individual Management Reviews to the SCRP

Once Individual Management Reviews are completed they will be circulated to all members of the Serious Case Review Panel, the Panel Chair and the Overview Author by the LSCP Administrator 2 weeks before the presentation meeting.

Key Features of the Presentation Meeting are:

  • Individual Management Review authors will present their reports to the SCRP and Overview Author and Chair sequentially throughout the day;
  • Authors are invited to identify the key findings of their work;
  • The meeting provides the Overview Author and Chair and the SCRP with an opportunity to engage in a dialogue with Single Agency Management Review Authors in order to “make sense” of issues central to the Case Review;
  • It also provides the opportunity to deal with omissions, questions, and queries arising from the different reports or between different reports/chronologies;
  • It is the first point at which key inter-agency practice issues begin to emerge.


13. Writing the Overview Report

The core information upon which the Overview Report is based arises from Individual Management Reviews and the discussion of emerging practice issues within the SCRP. The Overview Report is expected to identify any significant discrepancies between those reports or perspectives (in fact or analysis) and seeks to reconcile them through discussion with authors and within the SCRP.

The Overview Report will address the issues identified in Chapter 8 of Working Together (2010) and case-specific issues from the agreed Terms of Reference. Guidance on the format of the Overview Report can be found at Paragraph at 8.40 of Chapter 8 of Working Together (2010).

It is vital that recommendations in the Overview Report are few, focussed and achievable.

When the Overview Author has produced the first draft report, this will normally be presented to the SCRP for discussion and comment. This discussion aims to enable the Overview Author to place his/her analysis in the current context of inter-agency work, thus increasing the likelihood of helpful recommendations for action. The final Overview Report however, should reflect the independent view of the author.

Several drafts may be produced and discussed before the report is finalised for endorsement by Solihull LSCP.

The SCRP MUST ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the Overview Report; to achieve this the final draft of the report should be distributed to IMR authors’ who must confirm that the report fully and fairly represents their information.

13.1 SCR Panel Responsibilities for the Overview Report

The SCR Panel should:

  • Ensure that it actively manages the SCR 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 SCR 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; and also with Ofsted Descriptors;
  • Commission and agree the content of the executive summary, 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 SCR Panel Chair and the overview author and the job titles and the employing organisations of all the SCR Panel Members;
  • Translate recommendations into an action plan that should be signed up to by the senior manager in each of the organisations which 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 and 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 executive summary and overview report.

The SCR Panel, on behalf of the LSCP, should quality assure the final SCR - that is, the IMR reports, the overview report, the executive summary and the action plan.

13.2 The Executive Summary

It is expected that an Executive Summary will be commissioned that accurately reflects the full overview report. The content of the executive summary needs to be suitably anonymised in order to protect the identity of children, relevant family members and others and to comply with the Data Protection Act 1998. Guidance on the format of the Executive Summary can be found at Paragraph 8.42 of Chapter 8 of Working Together (2010).

The primary purpose of the Executive Summary is to set out the key elements in the Case Review, namely:

  • The purpose and scope of the Case Review;
  • An outline of the Review Process, including the organisations involved in providing information;
  • A brief outline of the circumstances which led to a Case Review;
  • A succinct account of key issues arising from the case;
  • Intended actions including any actions that have been competed.

The Executive Summary can be used in the following way:

  • A demonstration of the way in which the LSCP has exercised its responsibilities in relation to death or injury of child/children; including reassuring the public that lessons have been learned and actions taken;
  • A basis for press briefings should the Serious Case Review process attract media attention;
  • An efficient means of informing Chief Officers and the inter-agency practice community of key learning arising from the review of practice;
  • Core information upon which to build more elaborate case specific training materials.

The Executive Summary is completed by the Overview Author. A draft should be circulated to the SCRP for comment before final endorsement by the LSCP.

Copies of all reports should be marked as draft until approved.

The LSCP should decide when to publish the executive summary and overview report and this decision should take account of the timing of the conclusion of relevant court cases and statutory processes as well as the need, where possible, to consider issues raised by Ofsted’s evaluation of the full SCR.

The LSCP should inform the Department of Education and Ofsted of the date of the publication of the executive summary, and ensure that Ofsted receives a copy of the published summary within one month of receipt of the Ofsted evaluation letter. The final version of the executive summary should be sent to SCR.SIN@ofsted.gov.uk.


14. Finalisation and Adoption of the Serious Case Review Report

The full SCR (IMR reports including action plans, the overview report including integrated chronology, the executive summary and the inter-agency action plan) needs to be formally adopted by Solihull LSCP. This will be preceded by a formal presentation of the report and draft action plan by the Chair of the SCRP to the Board in conjunction with the Overview Report Author. The presentation will ensure that:

  • The LSCP is satisfied that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the Overview Report;
  • The recommendations and action plans are sufficiently robust to ensure learning from the case;
  • Arrangements for dissemination of report are in place;
  • As required, any media strategy is agreed on a multi-agency basis in accordance with Solihull LSCP Procedures.

A central purpose of the adoption meeting is to allow discussion amongst Board members on the case and to secure their commitment at a Senior Officer level to implementing the report’s recommendations according to the framework set out in it.

The LSCP will also need to ensure that information which becomes available from other processes, e.g. criminal trial, is considered by the SCRP to review if it impacts on lessons to be learnt. If this is the case the SCR cannot be adopted until all information has been considered by the SCRP and the LSCP will ensure that this does not prevent lessons from being learnt.

Once the LSCP has adopted the SCR and its recommendations, it is sent to the Performance Monitoring sub group to monitor implementation of action plans.

The LSCP will send copies of the full relevant SCR to Ofsted, the SHA, the Department of Education* and any other body depending on the nature of the case.


15. Retention of Papers

The sensitive nature of information contained within Individual Management Reviews and the Overview Report must not be underestimated. There is a balance to be kept between sharing information widely in order to increase participation, ownership and learning, and the appropriate management of personal and professional detail.

The following practice will, in most instances, minimise the chances of inappropriate disclosure.

CRP Members will:

  • Treat all papers relating to the SCRP’s work as confidential;
  • Keep papers locked and secure during the process of a Case Review;
  • Once the final SCR has been agreed and its recommendations accepted at LSCP, SCRP members will destroy all paper copies of the final report as the original will be kept by the LSCP Administrator.

Each LSCP partner organisation will:

  • Make arrangements for the secure retention of a single copy of their own Individual Management Reviews;
  • Ensuring that all draft copies of the Overview Report are shredded;
  • Once the final copy of the SCR has been agreed and its recommendations accepted at LSCP, LSCP members will destroy all copies of the overview report as the original will be kept by the LSCP Administrator.

The LSCP Administrator responsible for the SCRP will:

  • Retain copies of all papers associated with a Serious Case Review for a period of 7 years;
  • Provide access to papers through application to the Chair of the LSCP;
  • Mark copies of all Overview Reports as draft until the report is approved and arrange for draft reports to be destroyed;
  • Retain a copy of the full SCR on behalf of the LSCP.

* mailbox.SCRPANEL@education.gov.uk


16. Communication Strategy

The LSCP will consider carefully who might have an interest in the outcome of reviews - for example elected and appointed members of authorities, staff, members of the child's family, the public and media – and how information should be made available to them.

In making these decisions the LSCP will consider the following:

  • 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 organisations and people involved;
  • The responsibility to provide relevant information to those with a legitimate interest; and
  • Constraints in sharing information when criminal proceedings are outstanding.

When developing a communication strategy the SCRP will need to consider the following:

  • Key Messages;
  • Audience and stakeholders;
  • Communication channels to make public the lessons learnt;
  • The need to brief inspectorates and relevant bodies in advance of the publication of the SCR;
  • Roles and responsibilities of key individuals;
  • To identify which agency will provide a communication lead including the issuing of press releases on behalf of Solihull LSCP;
  • Support offered to families;
  • Briefing of staff on the contents of the report;
  • Briefing of the families and those involved in the compilation of the report;
  • Available resources for publication;
  • Debriefing arrangements to those involved;
  • The need for any media training.

Appendix 9: Overview Report Communications Plan provides a framework for developing a communication strategy.

16.1 Debriefing and Dissemination

The LSCP will arrange for practitioners directly involved in the case to receive feedback once the LSCP has approved the SCR in advance of wider dissemination. This will be in the form of a multi-agency practitioners de-briefing session and a standard letter of invitation can be found at Appendix 10: Letter of Invitation to a Practitioners De-Briefing.

Furthermore, the LSCP will ensure learning is incorporated into local training programmes.


17. Implementation and Monitoring of the Action Plan

As the purpose of SCR’s is to learn lessons for improving both individual and inter-agency working, the LSCP will be required to have in place a robust system for implementation of the Action Plan as well as monitoring and auditing the actions of all agencies against recommendations and intended outcomes. To this end, a standardised Action Plan Template will be used which from the outset will set out clearly the action required, by whom, when, the measure of achievement as well as the evidence required and audit activity that will demonstrate that lessons have been learnt. The action plan template can be found at Appendix 13: Action Plan Template.

The LSCP should formally conclude the SCR Process by signing off the completion of the action plan.


18. Learning Lessons on Process

After the IMRs, the Overview Report, the Executive Summary and the Action Plans have been submitted to Ofsted, a letter will subsequently be sent from the Regional Manager of Ofsted to the Chair of the LSCP. This letter will identify which Ofsted inspector carried out the grading of the SCR; it will confirm the overall effectiveness grading for the total SCR process; and it will then identify the individual gradings for each element of the SCR, i.e. the depth of learning evidenced by the review; the quality of the recommendations and the action plan; and the quality of the review process (for details of the Ofsted gradings see Appendix 12: Ofsted Descriptors).

It is crucial that the Chair of the LSCP, the LSCP Business Manager and the Independent Chair and Independent Author of the SCR study and analyse this letter at the earliest opportunity; reflecting on all aspects of the Ofsted grading, and particularly highlighting good practice that has been identified. Furthermore, it may be deemed appropriate for the SCR panel to reconvene for this purpose.

Ofsted will always offer a discussion with the Inspector who has carried out the evaluation and the LSCP should ensure that the feedback from Ofsted is used to enhance capacity to learn lessons at a local level.


Appendices

Appendix 1: Consideration of Case for Serious Case Review - Referral Form

Appendix 2: Letter Advising of a Serious Case Review Request to LSCP Agency Members

Appendix 3: Leaflet for Parents

Appendix 4: Letter of Invitation to Authors Briefing

Appendix 5: Letter for Commissioning Individual Management Reviews

Appendix 6: Standard Format for an Individual Management Review

Appendix 7: Chronology Template

Appendix 8: Interview Format

Appendix 9: Overview Report Communications Plan

Appendix 10: Letter of Invitation to a Practitioners De-Briefing

Appendix 11: Flowchart - Performance Management Plan And Timescales

Appendix 12: Ofsted Descriptors

Appendix 13: Action Plan Template

Appendix 14: IMR Author Guide

Appendix 15: Guidance on Drawing a Genogram

Appendix 16: Competence Framework for Serious Case Review Independent Authors and Serious Case Review Independent Chairpersons

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