Child Safeguarding Practice Reviews tools and pathways

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This procedure covers the requirements within chapter 4 of Working Together to Safeguard Children 2015, which describes the way Serious Case Reviews should be initiated and scoped and the principles to be used when undertaking Serious Case Reviews, as well as other forms of reviews and audits.

Serious Case Review Process

Criteria and Purpose

A Serious Case Review must be arranged when:

• A child has died (including death by suicide), and abuse or neglect is known or suspected; or
• A child has been seriously harmed, and abuse or neglect is known or suspected and there is cause for concern about the way in which the local authority, their Board partners or other relevant persons have worked together to safeguard the child; or
• A child dies in custody, whether in police custody, on remand or following sentence, or where the child was detained under the Mental Health Act 2005.

The purpose of a serious case review is:

• To understand not only what happened in the case but also why; and
• To establish what action will be taken to learn from the review findings and how this will produce lasting improvements in services for the prevention of death, serious injury or harm to children.

Serious case reviews are not inquiries into how a child died or was harmed, or who is culpable. These are matters for coroners and criminal courts to determine.

Decision Whether to Initiate a Serious Case Review

All cases that may meet the criteria for undertaking a serious case review must be reported to the Serious Case Review Sub-Group who will consider whether the criteria are met.

The Chair of the Serious Case Review Sub-Group will pass the Sub-Group’s recommendation to the Chair of the Safeguarding Children Board, who will decide whether a serious case review will be held. This decision must be made within one month of the case being brought to the Chair’s attention.

The Chair of the Safeguarding Children Board must notify the national panel of independent experts about the decisions made to arrange, or not to arrange, a serious case review. If the decision is not to arrange a serious case review the Chair must let the panel know within 14 days, by emailing the secretariat. This should include an explanation of why the case does not meet the SCR criteria and a copy of the local authority’s Serious Incident Notification or, if that is not available, brief anonymised details of the case including:

• The nature of the incident;
• The ages of the children involved;
• Their relationship with any alleged perpetrator(s);
• Agency involvement with the family; and
• Any criminal investigation.

Appointing Reviewers

The Chair of the Safeguarding Children Board will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews using the Learning and Improvement Framework Procedure, Principles for a Culture of Continuous Improvement.

The lead reviewer should be independent of the LSCB and the organisations involved in the case.

The LSCB will provide the National Panel of Independent Experts with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.

Working Together 2015 does not specify the need for an independent chair for the review process: the need for this will depend on the review model selected, the complexity of the case and other local considerations. The approach should be proportionate to the scale and level of complexity of the issues being examined.

Terms of Reference

The Serious Case Review Subgroup will establish a panel to draw up terms of reference for the review, and to manage the process. The Chair of the Serious Case Review Subgroup will ensure that the terms of reference address the key issues in the case before approving them.

As the review progresses, the serious case review panel may revisit the terms of reference in the light of new information. Any amendment must be agreed by the Chair of the Safeguarding Children Board.

Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings):

• The serious case review panel will prepare an update on progress and a revised project plan;
• The serious case review panel will notify the Chair of the Safeguarding Children Board; and
• The Chair of the Safeguarding Children Board will inform Ofsted of the new completion date and the reason for the extension.

The update should include:

• Recommendations for action that are not dependent on the review being concluded;
• Actions taken to date;
• An explanation of the extension to the timescale; and
• The revised completion date.

Engagement of Organisations

The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

Professionals must be fully involved in reviews and should be invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Families, including surviving children should be invited to contribute to ensure that the child is the centre of the review process.

The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

Individual Management Reviews

On being notified that a case is being considered for individual management review, each relevant service should secure records relating to the case to guard against loss or interference.

When it is decided that a serious case review will be undertaken, each Service Director will identify an author for the individual management review -this must be someone who has not been directly concerned with the child or family, or the immediate line manager of any of the practitioners involved. The Service Director will write to the author requesting that the review be completed within one month. A copy of the request should be sent to the Assistant Director Safeguarding in the Directorate for People.

The chair of the serious case review panel will arrange a briefing for authors of individual management reviews, responsible senior managers and the author of the serious case review which will:

• Discuss terms of reference;
• Discuss quality assurance;
• Address any gaps; and
• Respond to any questions.

The aim of an individual management review is to look critically at individual and organisational practice and at the context within which practitioners were working to see whether improvements could be made and, if so, to identify how those changes can be brought about.

When the individual management report is completed, the Service Director who commissioned it will sign it before sending it to the Assistant Director Safeguarding and Development in the Directorate for People.

An electronic version of each completed individual management review will be sent to the coordinator of the Child Death Overview Panel who will forward it to members of the serious case review panel for the case. Copies will also be sent to the Assistant Director Safeguarding in the Directorate for People.

The Overview Report

The serious case review panel will commission an overview report that brings together and analyses the findings of the various individual management reviews and makes recommendations for future action. The author of the overview report must be independent of all the local agencies and professionals involved and of the Safeguarding Children Board.

The overview report will bring together the information and analysis contained in the individual management reviews, information from the child death review processes and reports commissioned from any other relevant interests.

The serious case review panel will translate the recommendations of the overview report into an action plan, identify the agencies that will be involved in implementing it, and invite the senior manager of each agency to sign up to the action plan.

The executive summary and the overview report must be anonymised to protect the identity of children, relevant family members and others.

Agreeing Improvement Action

When the overview report is completed it will be presented to the Serious Case Review Sub-Group and then to the Safeguarding Children Board.

The Safeguarding Children Board will:

• Approve the final serious case review report;
• Ensure that anonymised copies of the individual management reviews, the overview report and the individual and multi-agency action plans, and the chronologies are provided to Ofsted and the Department for Education;
• Make arrangements to provide feedback and debriefing to staff and the media as appropriate;
• Disseminate the executive summary and key findings to relevant interested parties;
• Publish the overview report
• Implement those actions for which the Safeguarding Children Board has lead responsibility;
• Monitor the timely implementation of the action plan; and
• When the action plan has been implemented, formally conclude the review process and inform the Department for Education of this decision.

The serious case review action plan is sent out to all agencies for implementation of the review’s recommendations. The officers with responsibility for acting on recommendations will provide evidence of action taken to the Assistant Director Safeguarding in the Directorate for People. The Assistant Director Safeguarding is responsible for monitoring implementation of the recommendations, and will provide quarterly updates to the Safeguarding Children Board.

Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or adult at risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

• Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
• Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
• Be suitable for publication without needing to be amended or redacted.

The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

• Actions already taken in response to the review findings;
• The impact these actions have had on improving services; and
• What more will be done.

The Chair of the Safeguarding Children Board will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, the Chair should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.

National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children 2015 introduced a National Panel of Independent Experts to advise and support LSCB's about the initiation and publication of Serious Case Reviews. The panel will report to the relevant Government departments their views of how the system is working. LSCB's should have regard to the panel’s advice on:

• Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
• Appointment of reviewers;
• Publication of Serious Case Review reports.

LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

Further Information

• Serious Case Review Quality Markers - Intended to support commissioners and lead reviewers to commission and conduct high quality reviews.

• LSCPR Regional Framework and Practice Guidance - The Birmingham Safeguarding Children Partnership (BCSP) Serious Cases Sub-Group is responsible for carrying out Child Safeguarding Practice Reviews (CSPR) and other Learning Reviews in order to learn lessons and make improvements to safeguarding systems to safeguard and promote the welfare of children.  

  The regional practice guidance should be read by local safeguarding partners, and all agencies involved in the Birmingham Safeguarding Child Partnership.