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Serious Case Reviews
The Purpose of Serious Case Reviews
8.1 The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. The lessons learned should be disseminated effectively, and the recommendations should be implemented in a timely manner so that the changes required result, wherever possible, in children being protected from suffering or being likely to suffer harm in the future. It is essential, to maximise the quality of learning, that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the SCR, irrespective of whether the child died or was seriously harmed. This perspective should inform the scope and terms of reference of the SCR as well as ways in which the information is presented and addressed at all stages of the process, including the conclusions and recommendations. Reviews may vary in their breadth and complexity but, in all cases, where possible lessons should be acted upon quickly without necessarily waiting for the SCR to be completed.
8.2 The purposes of SCRs carried out under this guidance are to:
- Establish what lessons are to be learned from the case about the way in which local professionals and agencies work together to safeguard and promote the welfare of children;
- Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and
- Improve intra- and inter-agency working and safeguard and promote the welfare of children.
8.3 SCRs 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.
8.4 When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been involved with the child or family. These SCRs 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 SCR should always be carried out when a child dies in custody, either in police custody, on remand or following sentencing, in a Young Offender Institution (YOI), a Secure Training Centre (STC) or secure children’s home, or where a child was detained under the Mental Health Act 2005.
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When Should a LSCB Consider Undertaking a Serious Case Review?
8.5 LSCBs should consider whether to conduct a SCR whenever a child has been seriously harmed in the following situations:
- A child sustains a potentially life-threatening injury or serious and permanent impairment of 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; or
- A parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or
- A child has been seriously harmed following a violent assault perpetrated by another child or 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.
8.6 The following questions may help in deciding whether a case should be the subject of a SCR. The answer ‘yes’ to one or more of these questions is likely to indicate that a SCR could yield useful lessons:
- Was there clear evidence of a child having suffered, or been likely to suffer, significant harm that was:
- Not recognised by organisations or professionals in contact with the child or perpetrator; or
- Not shared with others; or
- Not acted on appropriately?
- Was the child abused or neglected in an institutional setting (for example, 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 whilst 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 local operation of formal safeguarding children procedures which go beyond the handling of this case?
- Was the child the subject of a child protection plan at the time of the incident, or had they previously been the subject of a 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 shared, understood or acted on?
- 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?
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Which LSCB should take lead responsibility?
8.9 Where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is or was normally resident should take lead responsibility for conducting the SCR. Any other LSCBs 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 LSCBs with an interest or involvement.
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Instigating a Serious Case Review
Does the Case Meet the Serious Case Review Criteria?
8.10 The LSCB Chair should consider whether a case might meet the criteria above. Where the child has died, the LSCB Chair should also use information available from the professionals involved in reviewing the child’s death to assist in making this decision. LSCBs should establish a Serious Case Review Sub-Committee involving representatives from local authority children’s social care, health (commissioning Primary Care Trust (PCT) and other partners as relevant), education, and the police at a minimum. Members of agencies which have responsibilities for completing Individual Management Reviews (IMRs) may be members of the SCR sub-committee but it should not consist solely of such people.
8.11 In some cases, it may be valuable to conduct a single individual management review rather than a full SCR, for example where there are lessons to be learned about the way in which staff worked witin one agency rather than about how agencies worked together, or a smaller scale audit of an individual case that gives rise to concern but does not meet the criteria for a SCR. In such cases arrangements should be made to share relevant findings with the SCR sub-committee or SCR Panel.
8.12 Following a decision by the LSCB Chair to undertake a SCR, the SCR sub-committee should commission a SCR Panel to manage the process. If the SCR sub-committee recommends that a SCR be undertaken, they should also recommend the scope and terms of reference for the review. These recommendations should be forwarded to the Chair of the LSCB, who has ultimate responsibility for deciding whether to conduct a SCR. The LSCB Chair should notify Ofsted of the outcome of this decision as soon as it has been made.
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Determining the Scope and Terms of Reference of the Review
8.13 The Review Panel should consider, in the light of current information known in each case, the scope of the SCR and draw up clear terms of reference. The LSCB Chair should ensure that the terms of reference address the key issues in the case and approve them. Relevant issues to consider include the following;
- 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, 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 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, for example independent professionals, independent schools, 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 LSCBs 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, the SCR sub-committee or 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 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 on how an NHS Serious Untoward incident (SUI) 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 others types of reviews e.g. 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 and/or the Crown Prosecution Service and to ensure that relevant information can be shared without incurring significant delay in the review process?
- 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?
- 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 LSCB?
Some of these issues may need to be re-visited as the review progresses and new information emerges. This reconsideration of the issues may in turn mean that the terms of reference will need to be revised and agreed by the LSCB Chair.
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Timescales for Initiating and Undertaking a Serious Case Review
8.14 Reviews vary widely in their breadth and complexity, but in all cases, where lessons are able to be identified, they should be acted upon as quickly as possible without necessarily waiting for the SCR to be completed. Within one month of a case coming to the attention of the LSCB Chair, he or she should decide following a recommendation from the SCR Sub-Committee, whether a review should take place. Individual organisations should secure case records promptly and begin to work quickly to draw up a chronology of involvement with the child and family.
8.15 Serious case reviews should be completed within six months from the date of the decision to proceed. Sometimes the complexity of a case does not become apparent until the review is in progress. If it emerges that a SCR cannot be completed within six months of the LSCB Chair’s decision to initiate it (perhaps because of judicial proceedings), the LSCB should revise its timetable and immediately consult the Ofsted Region to agree a timescale for completion.
8.16 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, for example, how does this affect timing, the way in which the review is conducted (including interviews of relevant personnel), its potential impact on criminal investigations and who should contribute at what stage? Serious Case Reviews should not be delayed as a matter of course because of outstanding family, civil or administrative court cases or an outstanding decision on whether or not to prosecute. Much useful work to understand and learn from the features of the case can often proceed without risk of contamination of witnesses in criminal proceedings. In some cases it may not be possible to the IMRs and the overview report or to finalise and publish an executive summary until after Coronial or criminal proceedings have been concluded, but this should not prevent early lessons learned from being acted upon.
8.17 The final SCR report, including the executive summary, should take full account of salient, new information which becomes available during the course of these proceedings and the facts, conclusions and recommendations should be revised accordingly.
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Who Should be involved in the Serious Case Review?
8.17 The initial scoping of the review should identify those who should contribute although it may emerge, as further information becomes available, that the involvement of others, such as those providing specialist adult services would be useful. In particular, information of relevance to the review may become available through criminal proceedings.
8.18 Each relevant service should undertake an independent management review of its involvement with the child and family. This should begin as soon as a decision is taken to proceed with a review and even sooner if a case gives rise to concerns within the individual organisation. Relevant independent professionals (including GPs) should contribute reports of their involvement. Designated safeguarding health professionals should review and evaluate the practice of all involved health professionals and providers within the Care Trust Plus area. This may involve reviewing the involvement of individual practitioners and NHS Trusts and advising named professionals and managers who are compiling reports for the review. Designated professionals have an important role in providing guidance on how to balance confidentiality and disclosure issues. Where a children’s Guardian contributes to a review, the prior agreement of the courts should be sought so that the Guardian’s duty of confidentiality under the court rules can be waived to the degree necessary.
8.19 The LSCB should commission an overview report which brings together and analyses
the findings of the various reports from organisations and others and which makes recommendations for future action.
8..20 The overview report should be commissioned from a person who is independent of all the local agencies/professionals involved and of the LSCBs. The overview report author should not be the chair of the LSCB, the SCR Sub-Committee or the SCR Panel. Those conducting management reviews of individual services should not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.
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Individual Management Reviews - General Principles
8.21 Once it is known that a case is being considered for review, each organisation should secure records relating to the case to guard against loss or interference.
8.22 The aim of management reviews should be to look openly and critically at individual and organisational practice and at the context within which people were working to see whether the case indicates that improvements could and should be made and if so, to identify how those changes can be brought about. The findings from the management review reports should be accepted by the senior officer in the organisation who has commissioned the report and who will be responsible for ensuring that recommendations are acted upon.
8.23 Upon completion of each management review report, there should be a process for feedback and de-briefing for staff involved, in advance of completion of the overview report by the LSCB. There may also be a need for a follow-up feedback session if the LSCB overview report raises new issues for the organisation and staff members.
8.24 Serious Case Reviews are not a part of any disciplinary enquiry or process, but information that emerges in the course of reviews may indicate that disciplinary action should be taken under established procedures. Alternatively, reviews may be conducted concurrently with disciplinary action. In some cases (for example, alleged institutional abuse) disciplinary action may be needed urgently to safeguard and promote the welfare of other children.
8.25 Where a child dies in or whilst under escort to or from a custodial setting (prison, young offender institution or secure training centre) the Prisons and Probation Ombudsman investigates and reports on the circumstances surrounding the death of that child. The investigation examines the child’s period in custody, including an assessment of the clinical care they received. The report would normally be made available to assist any Serious Case Review process. In such cases a representative of the Youth Justice Board (YJB) should be a member of the SCR Panel to help ensure that relevant youth justice issues are covered. The SCR terms of reference should set out how the Prisons and Probation Ombudsman, the SCR Panel and the SCR Sub-Committee will work together to share relevant information during the process of undertaking the SCR.
8.26 The following outline format should guide the preparation of management reviews, to help ensure that the relevant questions are addressed and to provide information to LSCBs in a consistent format to help prepare an overview report. The questions posed do not comprise a comprehensive checklist relevant to all situations. Each case may give rise to specific questions or issues that need to be explored and each review should consider carefully the circumstances of individual cases and how best to structure a review in the light of those particular circumstances.
8.27 Where staff or others are interviewed by those preparing management reviews, a written record of such interviews should be made and this should be shared with the relevant interviewee. If the review finds that policies and procedures have not been followed, relevant staff or managers should be interviewed in order to understand the reasons for this.
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Scope and Format of Individual Management Reviews
What was our involvement with this child and family?
8.28 Construct a comprehensive chronology of involvement by the organisation and/or professional(s) in contact with the child and family over the period of time set out in the review’s terms of reference. (This chronology should clearly set out when the child was seen and whether the wishes and feelings of the child were sought). Briefly summarise decisions reached, the services offered and/or provided to the child(ren) and family and other action taken.
8.29 Where an agency has had relevant contact with the alleged perpetrator, the chronology should also cover these actions and should ask whether everything was done which might reasonably have been expected to manage effectively the risk of harm posed by the alleged perpetrator to the child.
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Analysis of Involvement
8.30 Consider the events which occurred, the decisions made and the actions taken or not taken. Where judgements were made, or actions taken, which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why something either did or did not happen.
8.31 Consider specifically:
- Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?
- Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?
- What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?
- Did actions accord with assessments and decisions made? Were appropriate services offered / provided, or relevant enquiries made, in light of assessments?
- Were there any issues, in communication, information sharing or service delivery, between those responsibilities for work during normal office hours and others providing out of hours services?
- Where relevant, were appropriate child protection or care plans in place and child protection and/or looked after reviewing processes complied with?
- When and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making revisions about children’s services. Was this information recorded?
- Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?
- Were senior managers, or other organisations and professionals involved at points where they should have been?
- Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and wider professional standards?
- Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resource issues such as vacant posts or staff on sick leave have an impact on the case?
- Was there sufficient management accountability for decision making?
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What Do We Learn From This Case?
8.32 Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children? Is there good practice to highlight, as well as ways in which practice can be improved? Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources? Are there implications for current policy and practice?
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Recommendations for Action
8.33 What action should be taken by whom and by when? What outcomes should these actions bring about, and in what timescales, and how will the organisation evaluate whether they have been achieved? Are there any immediate statutory requirements for the notification of concerns and are there likely to be any media handling issues?
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The LSCB Overview Reports
8.34 The LSCB overview report should bring together and draw overall conclusions from, the information and analysis contained in the individual management reviews, information from the child death review processes, where relevant, together with reports commissioned from any other relevant interests. Overview reports should be produced according to the following outline format although, as with management reviews, the precise format will depend upon the features of the case. This outline is most applicable to abuse or neglect that has taken place in a family setting.
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Format of an LSCB Overview Report
Introduction
8.35
- Summarise the circumstances that led to a review being undertaken in this case.
- State terms of reference of review.
- List contributors to the review and the nature of their contributions (e.g. management review by Local Authority, report from Adult Mental Health Service).
- List the names of the LSCB Chair, SCR Panel Chair, and author of overview report and the job titles and employing organisations of all the SCR Panel members.
- List parallel processes, if any that are being conducted (for example criminal proceedings)
The Facts
8.36
- 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 wishes and feelings were sought or expressed.
- Prepare an overview which summarises what relevant information was known to the agencies and professionals involved, about the parents/carers, any perpetrator and the home circumstances of the children.
- 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.
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Analysis
8.37 This part of the overview report should look at how and why events occurred, decisions were made, and actions taken or not taken. This is the part of the report where 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 review should be considered alongside learning from previous SCRs undertaken by the LSCB and findings from relevant research.
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Conclusions and Recommendations
8.38 This part of the report should summarise what, in the opinion of the review panel, are the lessons to be drawn from the case and how those lessons 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 reports from each organisation. 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
8.39 Overview panels will always ensure that appropriate members of the child’s family are invited to contribute to the overview process. The panel, in deciding who should be approached and how their contribution should be made, will need particular care. Timing of this involvement will also need careful handling in order not to prejudice or inhibit any other proceedings or investigations being conducted.
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The Executive Summary
8.40 In all cases, the SCR overview report and the IMRs should be used to produce an executive summary that should be made public and which accurately reflects the full overview report. The executive summary should include information about the review process, key issues arising from the case, and the recommendations and the action plan (including any actions that have been completed). The content of the executive summary needs to be suitably anonymised in order to protect the identify of children, relevant family members and others and to comply with the Data Protection Act 1998. The executive summary should, however, include the names of the LSCB Chair, SCR Panel Chair, the overview report author, and the job titles and employing organisations of all the SCR Panel members. Executive summaries should be produced according to the following outline format, although, as with IMRs and overview reports, the precise format will depend on the features of the case.
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Format of the Serious Case Review Executive Summary
8.41 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.
8.42 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.
8.43 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?
8.44 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.
8.45 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.
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LSCB Action on Receiving Reports
8.46 On receiving an overview report the LSCB should:
- Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report;
- Commission and agree the content of the executive summary for publication, ensuring it accurately represents the full SCR, includes the action plan in full and that all personal information relating to children, family members and professionals involved with the case is fully anonymised (apart from including the names of the LSCB Chair, SCR Panel Chair and the overview author and the job titles of the employing organisations of all the SCR Panel members);
- Translate recommendations into an action plan which should be signed up to at a senior level by each of the organisations that need to 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;
- Implement actions for which the LSCB has lead responsibility and monitor the timely implementation of the action plan
- Clarify to whom the report, or any part of it, should be made available;
- Disseminate the executive summary report of key findings to interests as agreed. Make arrangements to provide feedback and de-briefing to staff, the child (if surviving) and family members/carers of the subject child and the media, as appropriate, following completion of the executive summary;
- Provide an anonymised copy of the overview report, executive summary, action plan and individual management reports and chronologies (apart from including the names of the LSCB Chair, SCR Panel Chair and the overview author and the job titles of the employing organisations of all the SCR Panel members) to Ofsted and the Department for Education.
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Reviewing Institutional Abuse
8.47 When serious abuse takes place in an institution, or multiple abusers are involved, the same principles of review apply but reviews are likely to be more complex, on a larger scale and may require more time. Terms of reference need to be carefully constructed to explore the issues relevant to the specific case. For example, if children are abused in a residential school, it is important to explore whether and how the school had taken steps to create a safe environment for children and to respond to specific concerns raised.
8.48 There needs to be clarity over the interface between the different processes of investigation (including criminal investigations); case-management, including help for abused children and immediate measures to ensure that other children are safe; and review, i.e. learning lessons from the case to reduce the chance of such events happening again. The different processes should inform each other. Any proposals for review should be agreed with those leading criminal investigations, to make sure that they do not prejudice possible criminal proceedings.
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Accountability and Disclosure
8.49 LSCBs should consider carefully who might have an interest in reviews – e.g. elected and appointed members of authorities, staff, the child who was seriously harmed and the subject of the review, members of the child’s family, the public, media – and what information should be made available to each of these interests. There are difficult interests to balance, among them:
- The need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others:
- The accountability of public services and the importance of maintaining public confidence in the process of internal review:
- The need to secure full and open participation from the different agencies and professionals involved:
- The responsibility to provide relevant information to those with a legitimate interest;
- The constraints on public information sharing when criminal proceedings are ongoing, in that providing access to information may not be within the control of the LSCB.
8.50 It is important to anticipate requests for information and plan in advance how they should be met. For example, a lead agency may take responsibility for de-briefing the child (where the review was undertaken in respect of a child who was seriously harmed) and family members, or for responding to media interest about a case, in liaison with contributing agencies and professionals. In all cases, the LSCB overview report should contain an executive summary, which will be made public, which includes, as a minimum, information about the review process, key issues arising from the case and the recommendations, which have been made. Neither the overview report itself nor the management reviews should be made publicly available. The publication of the executive summary will need to be timed in accordance with the conclusion of any related court proceedings. The content will need to be suitably anonymised in order to protect the confidentiality of relevant family members and others. The LSCB should ensure that Ofsted, the Department for Education and other relevant bodies respectively are fully briefed in advance about the publication of the executive summary and overview report.
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Learning Lessons Locally
8.51 Reviews are of little value unless lessons are learned from them. At least as much effort should be spent on acting upon recommendations as on conducting the review.
The following may help in getting maximum benefit from the review process:
- As far as possible, conduct the review in such a way that the process is a learning exercise in itself for all those who have been involved with the case;
- Consider what type and level of information needs to be disseminated, how and to whom, in the light of a review. Be prepared to communicate both examples of good practice and areas where change is required;
- Focus recommendations on a small number of key areas, with Specific, Measurable, Achievable, Relevant and Timely proposals for change and intended outcomes; CTPs should feedback from the Strategic Health Authority who should use it to inform their performance management role;
- The LSCB should put in place a means of auditing action against recommendations and intended outcomes;
- Seek feedback on review reports from Ofsted who should use reports to inform inspections and performance management.
8.52 Day to day good practice can help ensure that reviews are conducted successfully and in a way most likely to maximise learning:
- Establish a culture of audit and review. Make sure that tragedies are not the only reason inter-agency work is reviewed;
- Have in place clear, systematic case recording and record keeping systems;
- Develop good communication and mutual understanding between different disciplines and different 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.
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Learning Lessons Nationally
8.53 Taken together, child death and serious case reviews should be an important source of information to inform national policy and practice. Ofsted is responsible for identifying and disseminating common themes and trends across review reports and acting on lessons for policy and practice. Ofsted will commission overview reports at least every two years, drawing out key findings of serious case reviews and their implications for policy and practice. It is considering how best to collate relevant findings from the work of the local child death overview teams.
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Please find attached to download at the bottom of this page the Overview of Serious Case Reviews Process diagram.