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7.1 Serious Case Reviews

RELATED CHAPTER

Child Death Overview Panel Procedure

RELATED GUIDANCE

Isle of Man SCB website - Serious Case Reviews


Contents                     

  1. Purpose of a Serious Case Review (SCR)               
  2. SCR Panel Membership                  
  3. SCR Panel Roles and Responsibilities                    
  4. Criteria for SCR    
  5. Single Agency Reviews (SARs)                            
  6. SCR Panel Consideration of SARs                   
  7. The Overview Report                         
  8. Summary Document                                  
  9. Options when the Criteria for a SCR are not Met              
  10. Retention of Papers                                  
  11. Learning Lessons
  12. Other Processes Impacting on SCR - Child Death Overview Panel

    Appendix 1: Referral Form for a Case to SCR Panel

    Appendix 2: Terms of Reference Proforma

    Appendix 3: Sample Notification Letter to Chief Officers

    Appendix 4: Sample Letter to Families

    Appendix 5: SAR Standard Format 

    Appendix 6: Chronology Template

    Appendix 7: Guidance on Completing a Genogram

    Appendix 8: SAR Agency Submission Form

    Appendix 9: Evaluating SARs – Practice Guidance for SCR Panel

    Appendix 10: SCB Action Plan Template

    Appendix 11: Inter-agency Case Review Template      


1. Purpose of a Serious Case Review (SCR)

1.1 The Safeguarding Children Board has established a PCR Panel (henceforth, the SCR Panel) to review cases and identify lessons to improve inter-agency working and better protect and safeguard children.
1.2

The purpose of SCRs carried out under this guidance is to: 

  • Establish what lessons are to be learned from the case about the way in which professionals and organisations work individually and together to protect and safeguard children;
  • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted upon, and what is expected to change as a result; and
  • Improve intra- and inter-agency working to better protect and safeguard children.


2. SCR Panel Membership

2.1

Overview

  2.1.1

Members of the SCR Panel will:

  • Act collectively to promote well evidenced and best practice standards;
  • Represent a professional or organisational view in relation to information brought before the SCR Panel;
  • Ensure a thorough and critically evaluated process of all the SAR reports and the Overview Report.
  2.1.2 In order to achieve stability and continuity within the SCR Panel the expectation is for membership to be as constant as possible.
  2.1.3

In selecting representatives each agency will choose a member of staff:

  • With sufficient knowledge and experience in the field to be able to fully contribute to and inform the debate;
  • Who is able to represent the organisations views, policies and practice and has an explicit mandate to do so;
  • Of sufficient seniority to ensure that recommendations arising from SCRs are addressed within their agency.
  2.1.4 Members of the SCR Panel will not combine this role with that of conducting Single Agency Reviews (SARs) as this could lead to a conflict of interest and prejudice their independence on the SCR Panel. A conflict of interest may also arise if the member was involved with the case as a practitioner, or as a line manager.

2.2

Deputising

  2.2.1 Agencies should be prepared to provide an alternative member for the SCR panel who is able to cover any absences of the standing member and can represent the agency should a case pose a potential conflict of interest for the standing member, or in the event that the standing member is unable to attend.

2.3

Current Membership

  • Independent Chair of the SCR Panel;
  • SCB Strategic Coordinator;
  • Senior Advisor, Dept of Education;
  • Assistant Director Social Services (Mental Health);
  • Consultant in Public Health medicine;
  • Director of Community Nursing;
  • Deputy Chief Constable;
  • Assistant Director Social Care (Children & Families).

2.4

Co-opted Membership

  2.4.1 Other Members may be co-opted to the Panel if their specialist skills are required for a particular case.

2.5

Legal Advice

  2.5.1

The SCR Panel may seek legal advice in respect of:

  • Liaison with other agencies in particular the Police and Attorney Generals Chambers to ensure that the case review process does not conflict with actual or potential prosecutions;
  • Analysis of new case law/statute affecting the review process;
  • Ad hoc advice to the Chair of the SCB and /or the SCR Panel as required during the process of a review.


3. SCR Panel Roles and Responsibilities

3.1

Overview

  3.1.1

The roles and responsibilities of the SCR Panel are as follows:

  • To decide whether or not a case meets the criteria for conducting a SCR and to make recommendations to the SCB Chair who has ultimate responsibility for the decision;
  • Where the criteria are met, to conduct a SCR in accordance with these guidelines;
  • To quality assure the SAR Reports and Overview Report;
  • Where the criteria are not met, for example when a child has not died, but has sustained serious injury and concerns are highlighted over inter-agency or single agency practice the SCR Panel has the discretion to initiate alternative action such as a management review of the case, an inter-agency audit or a facilitated learning event;
  • To determine the scope of each case review through commissioning SAR Reports, drawing up terms of reference and setting out timescales;
  • To give consideration to the impact of parallel processes for example criminal investigations and disciplinary procedures;
  • To ensure that the identified Chief Executive Officer for each agency understands the responsibilities of their agency, including the requirement to produce an SAR signed off by themselves or a designated senior officer;
  • To consider the wider issues of accountability and disclosure. To identify who might have an interest in the case review (for example Chief Officers, Ministers, Members, the Coroner, staff, members of the child’s family, the public and the media) The SCR Panel will need to consider what information should be made available to each identified interested party, seeking legal advice and the views of the SCB Chief Executives where appropriate;
  • To ensure that an Overview Report with recommendations for action is produced and that it brings together the information and analysis within the SARs with information and analysis from reports commissioned from any other relevant parties;
  • To ensure the timely production of an anonymous Summary document for agreed circulation and usage;
  • To commission the development of training materials;
  • To agree at what points it would be useful to hold briefing and debriefing meetings for the practitioners involved with the case;
  • To oversee the preparation of the learning points and develop a dissemination strategy to ensure that lessons are properly distributed;
  • To arrange the presentation of the Overview Report to the SCB and other relevant persons;
  • To develop an action plan based on the recommendations of the Overview Report;
  • To audit and monitor the implementation of the action plans across partner agencies and within the SCB.

3.2

Referral of Cases to SCR Panel

See Appendix 1: Referral Form for a Case to SCR Panel

  3.2.1 Cases where the criteria for a SCR may be met should be discussed in the first instance with the Strategic Coordinator and then with the Chair of the SCB and the Chair of the SCR Panel. Referrers will be asked to use the relevant form (see Appendix 1). Referrals will normally be countersigned by the Senior Manager within the agency before being forwarded to the SCR Panel.
  3.2.2 Depending on the timing of the referral it will be discussed at the next SCR Panel or a meeting will be specially convened. The representative on the SCR Panel or a senior manager from the referring agency will be invited to attend to present the referral.
  3.2.3 Members of the SCR Panel will be expected to attend the first meeting with relevant basic information on the child and family held by their agency for consideration and to assist decision making.

3.3

Safeguarding Siblings or Other Children

  3.3.1 When a child dies or is seriously harmed, and abuse or neglect is known or suspected to be a factor, the first priority of the SCR Panel should be to consider immediately whether there are other children who are suffering, or likely to suffer, significant harm and who require protection or safeguarding (for example, siblings or other children in an institution where abuse is alleged).

3.4

Timescales for SCRs

  3.4.1 The primary purpose for conducting SCRs is to contribute to the improvement of inter-agency practice through the learning of lessons and although cases will vary in their breadth and complexity the SCR Panel needs to ensure that lessons are learnt and acted upon as quickly as possible.
  3.4.2 In the event of a referral relating to a child death or significant harm likely to meet the criteria for a SCR the SCR Panel will meet within one month to consider whether the criteria are met. If the decision is yes, the review should aim to be completed within a further six months.
  3.4.3 The timescale will be reported to the SCB and the reasons for any delay agreed with the SCB Chair.

3.5

Interface with Other Proceedings

  3.5.1 SCRs should not be delayed as a matter of course because of outstanding family, civil or administrative court cases. In some cases it may not be possible to complete or to publish the review findings until after the Coroner’s or criminal proceedings have been concluded, but this should not prevent early lessons learnt from being implemented.

3.6

Reviewing Institutional Abuse

  3.6.1 Where the referral relates to serious abuse in an institution or multiple abusers are involved, the same principles of review apply. Reviews are likely to be more complex, on a larger scale and may require more time. The terms of reference for such case reviews need to be carefully constructed to explore the issues relevant to the specific case. For example if children have been abused in a residential school, it is important to explore whether and how the school has taken steps to create a safe environment for children and to respond to specific concerns raised.
  3.6.2

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;
  • Review learning the lessons from the case to reduce the chance of other such events happening again.
  3.6.3 The three different processes should inform each other. Any proposals for review should be agreed with those leading the criminal investigations to make sure that they do not prejudice possible criminal proceedings.


4. The Criteria for a SCR

4.1

Overview

  4.1.1

There are two sets of criteria for undertaking a SCR. One in circumstances in which a child has died and the other when a child has been seriously harmed.

  • When a child has died

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 SCB 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 Social Services 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, or in Secure Accommodation on the Island.

  • When a child has been seriously harmed

The SCR Panel will 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 as a result of Domestic Abuse; or
  • A child has been seriously harmed following a violent assault perpetrated by another child or an adult;

and

Where the case gives rise to concerns about the way in which professionals and services worked together to protect and safeguard the child/children. This includes inter-agency and/or inter-disciplinary working.

4.2

Decision Making

  4.2.1 There are several steps in reaching a decision as to whether or not a SCR should be commissioned.
  4.2.2

At the SCR Panel meeting:

  • Any member who is unable to attend should brief a deputy with the relevant information to attend in their stead;
  • The Independent Chair of the SCR Panel should ensure that the referral is discussed fully and that all views are heard;
  • The decision about whether or not to conduct a SCR will be based on the majority view with any dissent recorded in the minutes;
  • The SCR Panel needs to consider whether or not the specified criteria are met.
  4.2.3 The Chair of the SCB has the ultimate responsibility for deciding whether or not to conduct a case review and must always be consulted by the Chair of the SCR Panel.

4.3

The Checklist

  4.3.1 The following questions will always be considered at the initial SCR Panel. The responses to each question will be recorded and included as an appendix to the Terms of Reference.
  4.3.2

A “yes” answer to several of the following is likely to indicate that a SCR will yield lessons for practice.

  • Was there clear evidence of a child having suffered or been likely to suffer significant harm that was;
    • Not recognised by organisations or individuals 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, secure accommodation, prison, children’s home)?
  • Was the child abused or neglected while being looked after by Social Care?
  • Was the child a member of a family that has recently moved from 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 on appropriately, by another?
  • Does the case indicate that there may be failings in one or more aspects of the operation of formal child protection 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 SCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately promulgated, understood or acted on?
  • Are there any indications that the circumstances of the case may have implications off Island for systems or processes, or that it is in the public interest to undertake a SCR?

4.4

Criteria for a SCR not Met

  4.4.1

If the SCR Panel decides that the criteria for a SCR is not met but have identified inter-agency practice issues and are of the view that valuable and new lessons can be learnt, then one or more of the following may be agreed as a way forward:

  • An inter-agency case review (ICR);
  • A multi-agency review (MAR);
  • A practitioners and managers facilitated review event focussing on specific inter-agency practice issues;
  • An inter-agency case audit carried out by the QA Group.
For more details on the above see Section 9, Options when the Criteria for a SCR are not Met.

4.5

SCRs – Terms of Reference

See Appendix 2: Terms of Reference Proforma.

  4.5.1 The SCR 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 SCR Panel Chair should ensure that the terms of reference address the key issues in the case.
  4.5.2

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 Summary document?
  • 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?
  • 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, independent healthcare providers or voluntary organisations?
  • Is there a need to involve organisations/professionals working in other SCB jurisdictions and what should be the respective roles and responsibilities of the different SCBs with an interest?
  • Will the SCB 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 (this person should not be the Chair of the SCB 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 the Isle of Man Constabulary (IOMC) significant case reviews where it is felt that organisational learning may be identified. 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 Health Service Serious Untoward Incident investigation into the provision of healthcare should be co-ordinated with a SCR.
  • How will the SCR terms of reference and processes fit in with those for other types of reviews – for example, for homicide, mental health or prisons?
  • How should the review process take account of a coroner’s inquiry, any criminal investigations (if relevant), family or other civil court proceedings related to the case? How will it be best to liaise with the coroner and/or the Attorney Generals Chambers and to ensure that relevant information can be shared without incurring significant delay in the review process?
  • Did the family’s immigration status have an impact on the child/children or on the parents’ capacities to meet their needs?
  • How should the review process take account of relevant lessons learned from the SCRs which have been undertaken on the Island.
  • 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?

4.6

Notification to Agencies

See Appendix 3: Sample Notification Letter to Chief Officers.

  4.6.1 Once a decision has been made by the SCR Panel to conduct a SCR and this decision has been endorsed by the Chair of the SCB a letter of notification will be sent to Chief Officers of the agencies involved, copied to the SCR Panel and members of the SCB.

4.7

Notifying Families

See Appendix 4: Sample Letter to Families.

  4.7.1 It is important that consideration is given to the best means of notifying families that a SCR is being undertaken. Generally best practice would be to share and explain a notification letter with a family through personal delivery by a professional from the lead agency.
  4.7.2 The timings of such notifications are crucial, particularly where there are current Police investigations. Where there are pending criminal proceedings involving the parents and or family members the decision about how and when to notify the family needs to take place within the SCR Panel with the Police representative present.
  4.7.3 Where appropriate the family will be invited to contribute to the review and a decision will be made at the scoping meeting who is best placed to meet with the family for this purpose.

4.8

Notifying Victims

  4.8.1 The SCR Panel will need to consider the best means of notifying victims of a SCR. For example where a review concerns historical abuse and the child victim is now an adult; a sensitively handled notification can be a positive experience, allowing some sort of closure. A personal approach to talk through the written information is likely to be best practice.

5. Single Agency Reviews (SARs)

5.1

Overview

  5.1.1 Once it is known that a case is being considered for review, each organisation should secure its records relating to the case to guard against loss or interference. Once it is decided that a SCR will be undertaken, individual organisations, having secured their case records promptly, should begin quickly to draw up a chronology of their involvement with the child and family
  5.1.2 The aim of SARs 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.
  5.1.3 The SAR 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. This senior officer will be responsible also for ensuring that the recommendations of the SAR, and where appropriate the overview report, are acted on. When completed the SAR must be signed off by the each contributing agency’s Chief Executive or Director.
  5.1.4 The Action Plan developed by the agency should form part of the SAR and should address each recommendation from the SAR. There should be no delay in implementing the Action plan.
  5.1.5 The SCB will require evidence of the agency actions and will audit the impact of specific recommendations on a planned basis. Ongoing reviews will take place with reports to SCB.

5.2

Briefings for Authors of SARs and the Overview Report

  5.2.1 The identified authors for the SARs will be expected to attend a briefing meeting in order that all authors hear the same messages and questions and queries can be dealt with.
  5.2.2

The following documents will be made available to authors on a confidential basis:

  • A copy of the letter to Chief Executives notifying that the review is taking place;
  • The terms of reference;
  • The pro forma for the chronology;
  • The SAR format.
  5.2.3 It will be explained to authors that there may be occasions when the Coroner requests copies of the SARs prior to holding an inquest.
  5.2.4

The briefing meeting will cover:

  • An explanation of the process for a SCR;
  • An opportunity to go over the background of the specific case;
  • A discussion of what is expected from report authors;
  • Confirmation of the agencies contributing to the case review;
  • The SCB report formats for the SARs and the overview report;
  • Clarification with authors that they understand the specific terms of reference for the case;
  • Clarification with authors that conclusions reached must be evidenced;
  • Clarification that the action plan must follow recommendations;
  • Contingency arrangements should new information come to light which significantly impacts on the case review;
  • Review the timetable for the case review process to ensure that the timescales set are achievable;
  • Discuss how to brief and interview staff;
  • Reinforce the importance of the SAR and action plan being signed off by the Chief Executive of each agency (The SCR Panel will not accept the report without this endorsement).
  5.2.5 If problems or issues arise for authors they should contact the SCB Strategic Coordinator for the SCB for advice and clarification.
  5.2.6 The Overview Report Author will be invited to attend the individual agency authors briefing and will be expected to attend, although there may be exceptional circumstances when they are unable to.

5.3

Single Agency Review (SAR) Report Format

See Appendix 5: SAR Standard Format;

And Appendix 6: Chronology Template.

  5.3.1 The areas to be covered by the individual agency authors are set out below in bold italics. There will also be specific terms of reference set by the SCR Panel.
  5.3.2 Essentially the aim of the SAR is to appraise individual and organisational practice, openly and critically, and also the context within which people were working.  Authors should differentiate between information and opinion. When expressing an opinion authors should explain how they have arrived at that view and provide supporting evidence with examples. Areas for changes in practice must be clearly identified and supported with specific and measurable recommendations for improvement.
  5.3.3 As a result of the review the underlying causes of any failures should be fully understood.

 

What was our Involvement with this Child and Family?

  5.3.4 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. See Appendix 6: Chronology Template.
  5.3.5 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.

 

The Child/Children

  5.3.6 SAR authors must remember that the case review is about a child or young person and consequently help the reader understand what life was like for the child.

 

Genogram/Family Tree

  5.3.7

All SAR authors are asked to provide a genogram/family tree of the composition of the child's family. It should not be assumed that Social Services are the only agency required to provide a Genogram. Different agencies will have different understandings of family members and relationships and combined these understandings can be informative.

See Appendix 7: Guidance on Completing a Genogram.

 

Analysis of Involvement

  5.3.8

In addition to the specific terms of reference set, consider the events that 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. Consider the following:

  • 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?
  • When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?
  • 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 the light of assessments?
  • Were there any issues, in communication, information sharing or service delivery, between those with 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?
  • 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 in the case where they should have been?
  • Was the work in this case consistent with each organisation’s and the SCB’s policy and procedures and with 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 resourcing issues such as vacant posts or staff on sick leave have an impact on the case?
  • Was there sufficient management accountability for decision making?
 

What do we Learn from this Case?

  5.3.9 Are there lessons from this case for the way in which organisations work to protect and safeguard 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 multi agency); management and supervision; working in partnership with other organisations; resources?  Are there implications for current policy and practice?

 

Recommendations for Action

  5.3.10 What action should be taken by whom and when? What outcomes should these actions bring, 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?

5.4

Interviewing Staff

  5.4.1 It is expected that as well as reviewing records authors will interview key members of staff in order to prepare their report. This will enable the author to go beyond written records. Authors should keep a written record of the interview and check these records for accuracy with the staff members who have been interviewed; however authors are not required to include these notes within their SAR but are expected to make reference to the information gained from staff interviews in the analysis of issues within their report.

 

Factual Information about the Interviewee

  5.4.2 Authors may find it useful to include details of designation and current workplace for the members of staff interviewed as well as where and when interviewed. The interviewees’ level of experience, qualifications and supervisory arrangements should be considered as part of the analysis.
  5.4.3 Authors may find it useful to give the staff to be interviewed a briefing note about the SCR process.

5.5

Involvement of Family Members

  5.5.1 Family members should only be contacted for inclusion in the process following approval by the SCR Panel and SCB Chair. If it is agreed to involve family members and interview them, authors should include a written record of this interview as an appendix and show what difference this made to the outcome of the review.

5.6

Endorsing SAR Reports within agency

See Appendix 8: SAR Agency Submission Form.

  5.6.1 SAR Authors must ensure that their report and action plan have been discussed with the senior managers in their own organisation and that the final report is signed off by their Chief Executive Officer/Director. Reports which are not clearly signed off will be returned.
  5.6.2 On completion of each SAR report there should be a process of feedback and debriefing for the staff involved in the case, in advance of completion of the overview report. There should also be a follow-up feedback session with these staff once the SCR report has been completed. It is important that the SCR process supports an open, just and learning culture and is not perceived as a disciplinary-type hearing which may intimidate and undermine the confidence of staff.
  5.6.3 Completed SARs should be sent electronically to the SCB Strategic Coordinator by the agreed deadline, in order for circulation to the SCR Panel in good time for their next scheduled meeting.


6. SCR Panel Consideration of SARs

6.1 See Appendix 9: Evaluating SARs – Practice Guidance for SCR Panel.
  6.1.1 Once the SARs have been completed they are considered by the SCR Panel. The Overview Author will be present at these meetings.
  6.1.2

The SCR Panel must consider each SAR report in terms of:

  • Quality of report;
  • The clarity of the content.
  6.1.3 If in the opinion of the SCR Panel the report requires further work, it will be returned to the Chief Officer and author with an explanation of why the SCR Panel has returned it including the timescale for return.

6.2

Monitoring SAR Action Plans

  6.2.1 Partner agencies will be expected to begin to implement recommendations from SARs as soon as they are identified.  The SAR recommendations must be regularly monitored by the agency who will also be required to report to the SCR Panel on progress. 
  6.2.2 The SCR Panel will inform the SCB will be informed of progress on the action plan and any problems which arise. The Board will agree arrangements to evaluate evidence that actions are completed.

6.3

Meeting between SAR Authors and the SCR Panel

  6.3.1 SAR authors may be expected to present their report to a meeting of the SCR Panel when the Overview Report writer will also be present. These meetings will provide an opportunity for discussion of issues central to the case review and for clarification of any issues. 
  6.3.2 Once the SARs are completed the SCR Panel will consider when best to hold a practitioner briefing. The IMR authors will be expected to identify the relevant staff within their agency to be invited to a practitioner briefing.

6.4

Briefings for Practitioners Involved in a Case Subject to Review

  6.4.1 The briefing meeting will be organised and facilitated by the SCR Panel to provide an opportunity to clarify and discuss the SCR process and its purpose.
  6.4.2 Details of the case will not be shared.
  6.4.3

Members of the SCR Panel and the Strategic Coordinator will facilitate the briefing. It will cover the following areas:

  • The SCR process;
  • The issues specific to the case review as outlined in the Terms of Reference;
  • An opportunity to raise any questions and queries.
  6.4.4 Practitioners are supported through the SCR process by their own organisation but they may also require advice about independent support.
  6.4.5 Case details will not be discussed.


7. The Overview Report

The Isle of Man SCB will always commission an Independent Overview Report Author to prepare the overview report for each SCR.

7.1

Appointing an Overview Author

  7.1.1

The Chair of the SCR Panel in conjunction with the SCB Strategic Coordinator and other SCB members will identify suitable candidates, dependent on the needs of each case review. Candidates will be asked to supply:

  • A Curriculum Vitae;
  • A referee who will be a Senior Manager or SCB Chair in an authority where they have recently written an Overview Report.
  7.1.2 There may be a telephone discussion and or meeting to ascertain that they are able to work within SCB requirements and in some instances an interview with members of the SCR Panel may be helpful.
  7.1.3 Once the Overview Author has been identified a commissioning letter and contract outlining terms and conditions for the case review will be drawn up by the SCB. The contract will include details of the time allocated, costs agreed, timescales for completion and the format required for the Overview Report. 

7.2

Attendance of Overview Author at SCB Meetings

  7.2.1 The Overview Author will be required to present the report to the SCB.
  7.2.2

Overview Authors will be invited to attend the following meetings:

  • Briefings for Individual Agency Management Authors;
  • SCR Panel meetings where reports are presented and discussed;
  • SCR Panel meetings to discuss the draft versions of the Overview Report and recommendations.

7.3

Preparing the Overview Report

  7.3.1 The SCR overview report should bring together, and draw overall conclusions from, the information and analysis contained in the SARs, any relevant information from the child death review process and reports commissioned from any other relevant interests.
  7.3.2 The Overview Author is expected to identify any discrepancies between the SAR reports and to seek to reconcile them through discussion with authors and the SCR Panel.
  7.3.3 The drafts of the Overview Report will be presented to the SCR Panel for discussion and comments. The discussions should enable the Overview Author to place the analysis within the current context of inter-agency work within the Isle of Man. However the final Overview Report should also reflect the independent view of the author.

7.4

Agreeing the Recommendations

  7.4.1 The recommendations within the Overview Report will be drawn up in consultation with the SCR Panel and agreed by the Panel.

7.5

Overview Report Format

 

Introduction

  • A summary of the circumstances and reasons leading to the SCR
  • Inclusion of the specific terms of reference for the SCR and how each SAR has addressed these
  • Record the methodology used including documents reviewed and whether the information was provided in interview or through written evidence
  • List agencies or types of contributors to the case review and the nature of their contributions. List the names and roles/positions/job titles of the SCB Chair, SCR Panel Chair, the author of the overview report and the job titles and employing organisations of all the SCR  Panel members
  • The Author should "talk the reader through the process" by outlining the process and conduct of the case review including details of outcomes from discussions with SAR authors with dates, challenges to the quality and contents of reports, any additional information sought, resubmission of reports and how any additional information required was gained.
 

Integrated Chronology

Using each of the chronologies submitted by the agencies contributing to the case review, an integrated chronology of involvement with the child and family will be drawn up by the SCB. This integrated Chronology will show each agency’s involvement with the child, the actions taken, each occasion on which the child was seen and whether the child’s wishes and feelings were sought and recorded.  In addition if agencies had contact with an alleged perpetrator the chronology should cover these actions.

 

The Facts

  • Prepare a 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
  • Consider explicitly any relevant ethnic, cultural or other equalities issues and whether these are relevant to the behaviours and approach taken by the organisations and professionals involved
  • Summarise the relevant information that was known to the agencies and professionals involved about the parents/carers, any perpetrator and the home circumstances of the children.
 

Analysis

This part of the overview report should look at how and why events occurred, decisions were made 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 SCR should be considered alongside learning from previous SCRs undertaken by the SCB and findings from relevant research.

7.6

Conclusions and Recommendations

  7.6.1 This part of the report should summarise what lessons are 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 usually be few in number, focused and specific, and capable of being implemented.

7.7

SCB Action Plan

See Appendix 10: SCB Action Plan Template.

  7.7.1 Once the overview report has been agreed by the SCR Panel the recommendations will be set out within an action plan showing how they are to be achieved, the timescales for this and how the implementation of the actions will be monitored and reviewed. The SCR Panel will be responsible for monitoring the implementation of actions arising from the Overview Report and will receive regular reports from agencies.
  7.7.2 Any recommendations relating to the SCB will be built into the SCB Work Programme.

7.8

SCR Panel Responsibilities for the Overview Report

  7.8.1

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;
  • 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;
  • Agree the content of the Summary document;
  • Clarify to whom in which agencies or organisations the Summary document and the action plan of the SCR should be made available to support implementation of the recommendations and the learning of the lessons;
  • Make recommendations on the above to the SCB and recommend arrangements for publication;
  • 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 Summary document.

7.9

SCB Action on Receiving Overview Report

  7.9.1

The SCB should approve the final overview report and:

  • Make arrangements to provide feedback and debriefing to staff and the media as appropriate;
  • Agree arrangements to disseminate the Summary document and key findings to relevant interested parties;
  • Consider whether or not to publish the Summary document;
  • Implement those actions for which the SCB has lead responsibility and monitor the timely implementation of the SCR action plan;
  • Formally conclude the review process when the SCB action plan has been implemented.

7.10

Additional Tasks for Overview Author

  7.10.1

In addition to the Summary document the SCB may commission additional pieces of work from the Overview Author for example:

  • Training materials to support dissemination of practice messages arising from the case review;
  • Contribution to workshop or seminars for practitioners and managers focussed on the learning from the case review.

7.11

Media Strategy

  7.11.1 Responsibility for the media strategy rests with the SCB in consultation with the SCR Panel Chair.

7.12

Dissemination Strategy

  7.12.1 Following an SCR a dissemination strategy will be drawn up by the SCB Strategic Coordinator to be agreed by the SCR Panel. It will summarise how the lessons to be learnt from the case review will be taken forward.


8. Summary Document

8.1 A Summary document, accurately reflecting the findings of the overview report, should be compiled following the SCB endorsement of that report.
8.2 The content of the Summary document needs to be suitably anonymised in order to protect the identity of children, relevant family members and others and to comply with data protection principles.
8.3

The Summary document should include information about:

  • The review process, key issues arising from the case;
  • The recommendations and progress made.
8.4 The primary purpose of producing the Summary document is to inform an agreed audience of the key elements of the SCR.
8.5

The Summary can also be used to:

  • Demonstrate the way in which the SCB has exercised its responsibilities in relation to the death or serious injury/incidents to children;
  • As a basis for press briefings should the case review attract media attention;
  • As an efficient means of informing Chief Officers and the inter-agency practice community of key learning arising from the review of practice.
8.6 Decisions about making the Summary available to a wider audience must be timed in accordance with the conclusion of any related proceedings. The decision to publish – and when - should be taken on a case by case basis by the SCB.


9. Options when the Criteria for a SCR are not Met

Where a case has been considered by the SCR Panel and it has been agreed that it does not meet the criteria for a SCR but the SCR Panel believes there are significant practice lessons to be learnt the following may be commissioned.

9.1

Inter-agency Case Review (ICR)

See Appendix 11: Inter-agency Case Review Template.

  9.1.1 Undertaking such a review allows the SCB greater flexibility than under the SCR process. Although there may be occasions where the process will mirror a SCR an ICR may be completed more speedily and can be more focused on specific issues as identified by the SCR Panel during the initial discussion. It may also provide a good opportunity to involve practitioners and managers more directly in cases where the SCB has identified there are useful lessons to be learnt about practice. The SCR Panel will prepare a summary report with recommendations for consideration.

9.2

Commissioning an Inter-agency Case Review (ICR)

  9.2.1 The SCR Panel will draw up Terms of Reference for the ICR setting out timescales for the review period and the areas to be addressed.
  9.2.2 The SCR Panel has developed a separate template for the completion of an ICR to assist authors. Agencies will be asked to complete a chronology of their agency involvement with the child and their family along similar lines to the requirement for a SCR.
  9.2.3 The Chair of the SCR Panel will write to the Chief Executives of those agencies involved with the case notifying them of the SCB’s intention to complete an ICR. The letter will request the identification of an internal author, who is independent of the case.
  9.2.4

A briefing meeting for the authors will be convened by the SCB Strategic Coordinator. The purpose of the meeting will be to:

  • Discuss and clarify the Terms of Reference for the ICR;
  • Clarify the focus and what the SCR Panel is hoping to achieve from the case review;
  • Discuss who needs to be involved in the process;
  • Confirm the timescale for completion of the review;
  • Discuss how the group will work with one another, the SCB Strategic Coordinator and the SCR Panel.
  9.2.5 The ICR group will work with the SCB Strategic Coordinator and produce a brief overview report with key findings and recommendations to be presented to the SCR Panel.
  9.2.6 The SCR Panel will report on the findings of the ICR to the SCB and will ensure that the recommendations are implemented and monitored.

9.3

Multi-agency Case Reviews

  9.3.1 The SCR Panel will draw up Terms of Reference for the ICR setting out timescales for the review period and the areas to be addressed.
  9.3.2

Each agency will identify a representative to:

  • Review the case;
  • Provide a chronology;
  • Make personal notes to bring to a discussion on the case in respect of any lessons for their agency;
  • Bring any interagency issues they would like to discuss.
  9.3.3 The Strategic Coordinator will arrange for the agency chronologies to be integrated into a composite document.
  9.3.4 The SCR Panel will meet with the agency representatives to discuss the case. 
  9.3.5 The discussion will be informed by the integrated chronology and each representative will be asked to share their views and answer any questions.
  9.3.6

It expected that this process will:

  • Demonstrate different understandings of the case;
  • Ways in which agencies do/don’t work together;
  • Identify the key events for the child;
  • Identify any misunderstandings and the impact of these;
  • Identify episodes of good practice;
  • Agree risks to child;
  • Identify any single agency or inter-agency lessons.

9.4

Facilitated Learning Day

  9.4.1 Such an event would involve a facilitator identified by the SCR Panel (who may or may not be independent) meeting with a group of practitioners and or managers who have been involved in a case. The event would provide the opportunity to consider the inter-agency working in the case, identifying practice issues and any barriers to achieving best outcomes. Recommendations from the event would be considered by the SCR Panel.

9.5

Inter-agency Case Audit

  9.5.1 There may be situations where a particular issue seems to have been significant in the harm or neglect of a child, or there may have been a number of cases with a common theme, in such circumstances the SCR Panel can recommend to the Quality Assurance (QA) group that an inter-agency case audit is undertaken. The QA may commission an independent auditor to complete the work or build the issue into any inter-agency audits already planned.


10. Retention of Papers

10.1 The sensitive nature of information contained within SARs and the Overview Report cannot be underestimated. There is a balance to be achieved between sharing information widely in order to increase awareness, ownership and learning and the appropriate management of personal and professional information. The following practices should assist in minimising the risk of inappropriate disclosure.
10.2

SCR Panel members will

  • Treat all papers relating to the SCR Panel as confidential;
  • Keep papers securely, and locked away when not in use, both during the case review process and afterwards;
  • Retain a single copy of the Overview report;
  • Destroy all other papers.
10.3

Each SCB partner organisation will:

  • Make arrangements for the secure retention of a single copy of their SAR and Overview Report.
10.4

The SCB Chair will make arrangements to:

  • Retain copies of all papers associated with a SCR for a period of 7 years;
  • Provide access to papers through application to the Chair of the SCR Panel.
10.5 It is not appropriate for the Overview Report and the integrated chronology to be held on the child’s case file.
10.6 It is for individual agencies to decide whether or not a copy of their SAR is held on a child’s file.
10.7 The Summary document may be placed on a case file.


11. Learning Lessons

11.1

Overview

  11.1.1 As the purpose of SCRs is to learn lessons for improving both individual agency and inter-agency working, they will be of little value unless the lessons are indeed learned and acted upon. This means that at least as much effort should be spent on implementing the recommendations as on conducting the review.

11.2

SCB Receives the SCR Report

  11.2.1

The SCR Overview Report will be presented to the SCB. At the same meeting the Board will receive:

  • A draft Action Plan based on the recommendations from the SCR;
  • The Action Plans emanating from those partner agencies who carried out a Single Agency Review with a report on progress;
  • A Dissemination Strategy recommending how the findings of the SCR are to be disseminated.
  11.2.2

The SCB will consider whether or not it is willing to accept the SCR Report.  If it is the Board will need to consider how to deal with the findings in respect of:

  • Political interest;
  • Public interest;
  • Media interest.

11.3

Practitioner Debrief

  11.3.1 Following the endorsement of the Overview Report and the development of the Action plan practitioners directly involved with the case will be invited to a de- briefing meeting. This meeting will provide practitioners with the opportunity to contribute to the discussion of the findings, for feedback from the Overview Report, the recommendations and action plan. Where possible the Overview Author will be present to offer further clarification of practice issues arising from the case.

11.4

Training and Development

  11.4.1 The SCB Training and Development Manager will be involved in the meetings where the Overview Report is presented in order to ensure that learning and action points from the case review informs plans for future training and other staff development opportunities, particularly in the locality where the child and their family were living.

11.5

Key Managers Seminars/Practitioner Workshops

  11.5.1 These are events for key managers, supervisors and practitioners who are or have been involved in the case which was subject of a SCR. The seminars and workshops will provide opportunities to discuss issues arising from the Overview Report, to promote shared responsibility for practice development and to build a culture of learning.

11.6

Training Toolkit

  11.6.1 A training toolkit may be developed; this will not have any identifying case information but should provide clear, consistent messages that can be used in single agency and inter-agency training and discussion forums.


12. Other Processes Impacting on SCRs - Child Death Overview Panel

12.1 The Child Death Overview Panel (CDOP) undertakes a review and analysis of all child deaths (under 18 years of age) on the Island. See Child Death Overview Panel Procedure.
12.2 The CDOP reviews each unexpected death of a child following evaluation by a rapid response team of key professionals.
12.3 The CDOP may determine through the review of each child death that the criteria for a SCR are potentially met. In these cases the CDOP will refer the case to the SCR Panel. Likewise the SCR Panel may identify cases that do not meet the criteria for a SCR but would meet the criteria for review by the CDOP.


Appendix 1: Referral Form for a Case to SCR Panel          

Click here to view 'Referral Form for a Case to SCR Panel'.    


Appendix 2: Terms of Reference Proforma      

Click here to view 'Terms of Reference Proforma'.             


Appendix 3: Sample Notification Letter to Chief Officers     

Click here to view 'Sample Notification Letter to Chief Officers'.      


Appendix 4: Sample Letter to Families    

Click here to view 'Sample Letter to Families'.   


Appendix 5: SAR Standard Format   

Click here to view 'SAR Standard Format'.                     


Appendix 6: Chronology template

Click here to view 'Chronology Template'.


Appendix 7: Guidance on Completing a Genogram   

Click here to view 'Guidance on Completing a Genogram'.        


Appendix 8: SAR Agency Submission Form

Click here to view 'SAR Agency Submission Form'.         


Appendix 9: Evaluating SARs – Practice Guidance for SCR Panel    

Click here to view 'Evaluating SARs – Practice Guidance for SCR Panel'.  


Appendix 10: SCB Action Plan Template

Click here to view 'SCB Action Plan Template'.


Appendix 11: Inter-agency Case Review Template 

Click here to view 'Inter-agency Case Review Template'.

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