19. Serious Case Review

Purpose of a serious case review

The purpose of a Serious Case Review is to:

• Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children;
• Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result, and as a consequence;
• To improve inter-agency working and better safeguard and promote the welfare of children.

When should a Local Safeguarding Children Board (LSCB) undertake a serious case review?

The LSCB should also consider a review when there are concerns about the way in which local professionals and services worked together with respect to a child:

• Who sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect; or
• Who has been subjected to particularly serious sexual abuse; or
• Whose parent has been murdered and a homicide review is being initiated; or
• Who has been killed by a parent with a mental illness; or
• Whose case gives rise to concerns about inter-agency working to protect children from harm.

Any professional may refer such a case to the LSCB if it is believed that there are important lessons for inter-agency working to be learned from the case.

In addition, the Secretary of State for the Department for Children, Schools and Families (DCSF) has powers to demand an inquiry be held under the Inquiries Act 2005.

The following questions may help in deciding whether or not a case should be the subject of a Serious Case Review. In circumstances other than when a child dies, the answer 'yes' to several of these questions is likely to indicate that a review could yield useful lessons:

• Was there clear evidence of a risk of Significant Harm to a child, which was:
  • Not recognised by organisations or individuals in contact with the child or perpetrator; or
  • Not shared with others; or
  • Not acted upon appropriately?
• Was the child killed by a mentally ill parent?
• Was the child abused in an institutional setting (e.g. school, nursery, family centre, Young Offender Institution, Secure Training Centre, children's home or armed services training establishment)?
• Did the child die in a custodial (prison, Young Offender Institution or Secure Training Centre) setting?
• Was the child abused while being looked after by the local authority?
• Did the child commit suicide or die while absent having run away from home?
• Does one or more agency or professional consider that its concerns 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 subject of a child protection plan or had it been previously 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 disseminated, understood or acted upon?

Initiating a serious case review

The LSCB Chair should convene a Serious Case Review panel involving at a minimum:

• A review panel chair;
• An administrator provided by the LSCB;
• The LA children's social care child protection adviser;
• The designated doctor and nurse, a senior member of the police, and an education representative;
• Senior professionals from other agencies who have a relevant contribution to an individual review.

Immediate action

As soon as the LSCB Chair has decided that a Serious Case Review is required, they must immediately inform the Chair of the serious case review panel. The LA child protection adviser must, within one working day, complete the following tasks:

• Confirm that arrangements have been made (where necessary via a Strategy Meeting) to ensure the safety of other children or family members;
• Check the LA children's social care client index to establish if the adult/s or child/ren are known;
• Check with the police and designated doctor and nurse for any relevant information;
• Secure the LA children's social care files;
• Inform the Director of Children's Services;
• Identify the agencies which have been involved with the child and alert them, via a letter from LSCB Chair to their chief executive, to their obligation to undertake an internal management review as a contribution to the overall serious case review;
• Inform Ofsted.

The early alert to relevant agencies should cover the need for nominated / designated child protection professionals to:

• Liaise with the case accountable children's social worker before making contact with the family;
• Secure files;
• Collate relevant procedures;
• Make arrangements for adequate support for the professionals involved.

Within two further working days, the LA child protection adviser should:

• Complete a briefing report for the Director of Children's Services, the LSCB and the case review panel;
• Submit the required report form to Ofsted following agreement with the Director of Children's Services.

Determining the scope of the review

The review panel should consider the scope of the review process for the individual case and draw up clear terms of reference. Relevant issues include:

• What appear to be the most important issues to address in trying to learn from this specific case? How can the relevant information best be obtained and analysed?
• Who should be appointed as the independent author for the overview report?
• What time period should be reviewed (i.e. how far back should enquiries cover), and what is the cut off point?
• What family history / background information will help to better understand the recent past and present?
• Whether agencies or professionals other than LSCB members automatically asked to conduct a management review should be asked to submit a report or otherwise contribute and how this is to be achieved (specialist tertiary hospital trusts may be involved in serious case reviews because of the nature of the services they offer, see Section 5.22.7)
• Whether there is a need to involve agencies / professionals from other LSCB areas and how this is best achieved;
• Whether and how to involve family members in the review;
• Whether an independent review (external to the LSCB) should be commissioned. This may be necessary under the following circumstances:
  • if it is possible that there may be a public inquiry;
  • where it is predictable that there will be significant public interest and external scrutiny is considered to be important;
  • if there has been a serious breakdown in inter-agency working at different levels; or
  • there are other major and serious situations involving significant child protection issues.
• The agreed timescales for completion of the review;
• Whether there is a need to bring in an outside expert at any stage to shed light on crucial aspects;
• Whether the case will give rise to other parallel investigations of practice (e.g. independent health investigation, homicide review);
• How should the review process take account of a coroner's inquiry and (if relevant) any criminal investigations or proceedings related to the case?  How best to liaise with the coroner and/or the Crown Prosecution Service?
• How should any public, family and media interest be managed, before, during and after the review?
• Does the LSCB need to obtain independent legal advice about any aspect of the proposed review?

Timescale for the review

The aim of management reviews should be to:

• Establish a factual Chronology of the action which has been taken within the agency;
• Analyse the involvement of the agency;
• Consider what lessons may be learned from the case about the way in which the agency works to safeguard children and promote their welfare;
• Recommend appropriate action in the light of the review's findings. This should include the intended outcomes and an expectation that the agency will review whether these have been achieved.

Management review format

What was our involvement with this child and family?

In analysing the involvement with the child and/or family, the following areas should be specifically considered:

• Were practitioners sensitive to the needs of children in their work, knowledgeable about potential indicators of abuse and neglect and what to do if they had concerns about a child?
• 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?
• 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 children'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 of the child and family?
• Were more senior managers or other organisations and professionals involved at points when they should have been?
• Was work on this case consistent with each organisation's and the LSCBs policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?

What do we learn from this case?

When analysing potential learning from the case, the following questions should be considered:

• 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?

Recommendations for action

When making recommendations for action, the following questions should be considered:

• What action should be taken, by whom and by when?
• What outcomes should these actions bring about, and how will the organisation evaluate whether they have been achieved?

Suggested format for LSCB overview reports

Introduction:

• Summarise the circumstances that led to a review being undertaken in this case;
• State terms of reference of review;
• List contributors to review and the nature of their contributions (for example, management review by local authority, report from adult mental health service).  List review panel members and author of overview report.

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 and the child's wishes and feelings sought or expressed;
• Prepare an overview which summarises what relevant information was known to the agencies and professionals involved about the parents, any perpetrators, and the home circumstances of the children.

Analysis:

• This part of the overview should look at how and why events occur, decisions were made, actions taken or not. This is the part of the report in which reviewers can consider, with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events. The analysis section is also where any examples of good practice should be highlighted.

Conclusions and recommendations:

• 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. 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.

Process of compiling the LSCB overview report

The Serious Case Review panel will:

• Consider the agency reviewing officers' reports. Each agency involved will determine what further action is required within their own agency. This will be included in their own agency review report and shared with the Serious Case Review subcommittee;
• Identify the key issues against the format for the overview report.

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;
• 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. The plan should set out who will do what, by when, and with what intended outcome. The plan should set out by what means improvements in practice / systems will be monitored and reviewed;
• Clarify to whom the report, or any part of it, should be made available;
• Disseminate the report or key findings to interested parties as agreed. Make arrangements to provide feedback and de-briefing to staff, family members of the subject child and the media, as appropriate;
• Arrange for an executive summary of the overview report to be compiled, which will provide a summarised and anonymised version of the report;
• Agree any urgent action arising from the Serious Case Review which requires immediate action;
• Provide a copy of the overview report, action plan and individual management reports to Ofsted and the Department for Children Schools and Families (DCSF).

Audit and monitoring

Accountability and disclosure

LSCBs should consider carefully who might have an interest in reviews - for example, elected and appointed members of authorities, staff, members of the child's family, the public, the media, and what information should be made available to each of these groups. 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;
• Constraints on public information sharing when criminal proceedings are outstanding, in that providing access to information may not be within the control of the LSCB.

Learning lessons locally

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, rather than a trial or ordeal;
• Consider what 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 and achievable proposals for change and intended outcomes; primary care trusts (PCTs) should seek 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.

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 / case review.

Learning lessons regionally and nationally