Serious Case Reviews
This document sets out the joint South West Local Safeguarding Children's Board's policy and agreed framework for executing its duty to undertake a systematic evaluation of inter-agency involvement in cases where a child has died or been seriously injured by a parent, family member or when significant harm has been caused by a carer. (See section 8, Working Together 2006)
It should be emphasised that the specific nature of individual cases requires that the framework should be adapted for different situations.
There are three appendices:
Individual Management Reviews
Example of Management Report
Overview Report
Serious case reviews (previously referred to as Part 8 Reviews) should be undertaken in the following circumstances:
"When a child dies, and abuse or neglect are known or suspected to be a factor in the death, local organisations should consider immediately whether there are other children at risk of harm who require safeguarding (For example siblings, other children in an institution where abuse is alleged). Thereafter, organisations should consider whether there are any lessons to be learned about the ways in which they work together to safeguard and promote the welfare of children. Consequently, when a child dies in such circumstances, the LSCB should always conduct a serious case review into the involvement with the child and family of organisations and professionals. (Working Together 2006, paragraph 8.2)
Working Together continues:
"Additionally, LSCBs should always consider whether a serious case review should be conducted:
where a child sustains a potentially life-threatening injury or serious and
permanent impairment of health and development through
abuse or neglect, or
has been subjected to particularly serious sexual abuse, or
their parent has been murdered and a homicide review is
being initiated, or
the child has been killed by a parent with a mental illness, or
the case gives rise to concerns about inter-agency working to protect children from harm".
(Working Together 2006, paragraph 8.2)
Working Together states that the purpose of such Reviews should be threefold, i.e.
To establish whether there are lessons to be learned from the case about the
way in which local professionals and agencies work together to safeguard children;
To identify clearly what those lessons are, how they will be acted upon, and what
is expected to change as a result; and
To improve inter-agency working and better safeguard and promote the
welfare of children.
It should be emphasised that serious case reviews are not enquiries into how a child died or who is culpable; that is a matter which Coroners and Criminal Courts respectively have to determine, as appropriate.
The following principles should underpin the execution of serious case reviews.
Agencies should take action immediately and follow this through as
quickly as possible.
Those conducting reviews should not have been directly concerned
with the child or family.
All important factors should be considered and there should be an
opportunity for all those involved to contribute.
There should be no suspicion of concealment.
Due regard must be made to the balance of individuals rights and
public interest.
Close collaboration between all the agencies involved
is required.
Action should be taken to implement any recommendations
that may arise and are accepted by the agencies concerned.
Working Together identifies a number of factors, which should be taken into account when deciding whether a serious case review should be undertaken.
A case review should always be undertaken when a child dies (including death by suicide), and abuse or neglect is known or suspected to be a factor in the child's death. This is irrespective of whether LA children's social care is or has been involved with the child or family.
Consideration should always be given to undertaking a case review where a child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect, and the case gives rise to concerns about the way in which local professionals and services work together to safeguard and promote the welfare of children. This includes situations where a parent has been killed in a domestic violence situation or where a child has been killed by a parent who has a mental illness.
Where more than one LSCB has knowledge of a child, the LSCB for the area in which the child is/was normally resident should take lead responsibility for conducting any review. Any other LSCBs that have an interest or involvement in the case should be included as partners in jointly planning and undertaking the review. In the case of looked after children, the responsible authority should exercise lead responsibility for conducting any review, again involving other LSCBs with an interest or involvement.
Any organisation or professional can refer a case to the LSCB Chair 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 of Education and Skills has powers to demand that an inquiry be held under the Inquiries Act 2005.
In deciding whether a case should be subject of a case review in circumstances other than when a child dies, the answer 'yes' to several of the following questions is likely to indicate that an inter-agency serious case review will yield useful lessons:
was there clear evidence of a risk of significant harm to a child which was:
not recognised by organisations or professionals 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, Children's Home, Armed Services Training Establishment)?
was the child abused being looked after by the local authority?
did the child commit suicide or die whilst absent having run away from home?
does one or more organisation 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 child protection procedures, which go beyond the handling of this case?
was the child subject of a child protection plan or had they been previously the subject of a plan or on the child protection register?
does the case appear to have implication for a range of organisations 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 adequately being promulgated, understood or acted upon?
South West LSCB's have standing Serious Cases Review Sub-groups. The membership of these sub-groups is made up of representatives from children's social care, education, health, police, probation and the NSPCC (it is a requirement of Working Together 2006 that those agencies indicated in bold are involved in assessing the need for a serious case review).
In making this decision where a child has died, this group should draw on information available from the professionals involved in reviewing the child's death (see Working Together 2006, Chapter 8 for details of the new child death review processes). Conversely, the child death review process may provide the trigger for a serious case review.
To consider, at the request of the Chair of relevant LSCB, whether a serious case review should take place, and to make recommendations to the LSCB Chair, who has ultimate responsibility for deciding whether or not such a review should be conducted. Such recommendations should detail:
the level and type of review that is indicated.
whether the investigation could be carried out by one or two agencies or whether a full serious case review overview panel is required.
the agency membership and chair for the overview panel.
who should chair the overview panel.
To determine, in the light of each case, the scope of the review process, and, as far as possible draw up clear terms of reference. (If a serious case review takes place, the first meeting of the Overview Panel will ratify and, if necessary, make additions or amendments to the terms of reference.) Relevant issues may include:
what appear to be the most important issues to address in trying to learn from the case?
how can the relevant information best be obtained and analysed?
are there features of the case that indicate that any part of the review process should involve, or be conducted by, a party independent of the professionals/organisations who will be required to participate in the review? Might it help the overview panel to bring in an outside expert at any stage, to shed light on crucial aspects of the case?
over what time period should events be reviewed, i.e. how far back should records be examined, and what should be the cut-off point? What family history/background information will help better understand the recent past and present which the review should try to capture?
which agencies and professionals should contribute to the review, and who else (e.g. proprietor of independent school, playgroup leader) should be asked to submit reports or otherwise contribute? It should be noted that, as information becomes available during the review, it may be necessary to seek the contribution of agencies who had not initially thought to have a significant role in relation to the case. In particular, information of relevance to the review may become available through criminal proceedings.
how should family members be invited to contribute to the review and who will facilitate their involvement?
will the case give rise to other parallel investigations of practice, (e.g. independent health investigations or multi- disciplinary suicide reviews, a homicide review where a parent has been murdered, a YJB Serious Incident Review and a Prisons and Probation Ombudsman investigation where the child has died in a custodial setting) and if so, how can a co-ordinated or jointly commissioned review process best address all the relevant questions which need to be asked, in the most economical way?
is there a need to involve agencies/professionals in other LSCB areas (see 00 Page377), and what should be the respective roles and responsibilities of the different LSCBs with an interest?
how should the review process take account of a Coroner's enquiry, and, if relevant, any criminal investigations or proceedings related to the case? How best can the LSCB liaise with the Coroner and/or Crown Prosecution Service?
how should the serious case review process fit in with the processes for other types of reviews, e.g. for homicide, mental health or prisons?
who will make the link with relevant interests outside the main statutory agencies, e.g. independent professionals, independent schools, voluntary organisations?
when should the review process start and by what date should it be completed?
how should any public, family and media interest be handled, before, during and after the review? Who will provide a link between the overview panel and the LSCB Media Sub-group?
does LSCB need to obtain independent legal advice about any aspect of the proposed review?
N.B. Some of these issues will need to be re-visited as the review progresses and new information emerges.
In some cases, it may be valuable to conduct individual management review or smaller scale audits of individual cases which give rise to concern but which do not meet the criteria for a full serious case review. In such cases, arrangements should be made to share relevant findings with the LSCB
The Local Authority has the responsibility of informing OfSted of every case that becomes the subject of a case review. This information will be passed to the DfES by them. The PCT should always inform its SHA of every case that becomes the subject of a serious case review.
Serious case reviews will vary widely in their breadth and complexity, but in all cases, lessons should be learned and acted upon as quickly as possible. Within one month of a case coming to the attention of the LSCB Chair, the decision should have been made by the LSCB Chair, following a recommendation from the Serious Case Review Sub-group (Panel), on whether a review should take place. Individual organisations should secure case records promptly and begin work quickly to draw up a chronology of involvement with the child and family.
Reviews should be completed within a further four months, unless an alternative timescale is agreed with OfSted at the outset. Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it emerges that a review cannot be completed within four months of the LSCB Chair's decision to initiate it, there should be a discussion with OfSted to agree a timescale for completion.
In some cases, criminal proceedings may follow the death or serious injury of a child. Those co-ordinating the review should discuss with the relevant criminal justice agencies how the serious case review process should take account of such proceedings, e.g. how does this affect timing, the way in which the review is conducted (including interviews of relevant personnel), and who should contribute at what stage?
Serious case reviews should not be delayed as a matter of course because of outstanding criminal proceedings 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 complete or to publish a review until after Coroner or criminal proceedings have been concluded but this should not prevent early lessons learned from being implemented.
Each relevant service or agency should undertake a separate 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 agency. Relevant independent professionals (including GPs) should contribute reports of their involvement. It is important that those conducting management reviews of individual services or producing the overview report should not have been directly concerned with the child or family, or the immediate line manager of the practitioners involved.
Designated professionals should review and evaluate the practice of all involved health professionals and providers within the PCT area. This may involve reviewing the involvement of individual practitioners and Trusts and also 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.
The Children & Family Court Advisory and Support Service (CAFCASS) is expected to contribute to the review, when felt appropriate by the LSCB, and should facilitate contributions. 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.
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.
Good practice would be that once a decision has been made that a serious case review should proceed, the Overview Panel should determine the interview strategy for individual agencies, with a view to disclosure issues that may be closely aligned to a criminal investigation. It would also be good practice for the Overview Panel to agree at an early stage the method of interviewing staff (e.g. reports, questionnaires, face to face interviews, records of the latter, notes which will be taken etc.)
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.
The aim of management reviews should be to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made, and if so, to identify how those changes will be brought about. 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.
Upon completion of each management review report, there should be a clear and agreed process for feedback and de-briefing for staff involved within individual agencies, 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. Once the overview report is complete and the executive summary has been published, the LSCB should hold a multi-agency debrief session, led by the Chair of the Overview Panel and at least one other panel member.
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 (e.g. alleged institutional abuse) disciplinary action may be needed urgently to safeguard other children.
Where a child dies in 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.
Appendix 1 provides guidance on the preparation of management reviews, to help ensure that the relevant questions are addressed. The questions posed do not comprise a comprehensive checklist relevant to all situations.
Each case may give rise to specific questions or issues which 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.
Appendix 2 illustrates the standard format to be used to provide information to the LSCB in a consistent manner to help preparing an overview report.
The LSCB will commission an overview report which brings together and analyses the findings of the various reports from agencies and others, and which makes recommendations for future action.
This report should be commissioned from a person who is independent of all the agencies/professionals involved.
The LSCB overview report should bring together and relate the information and analysis contained in the individual management reviews, together with reports commissioned from any other interests.
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, together with reports commissioned from any other relevant interests.
Overview reports should be produced according to the outline format in Appendix 3 although, as with management reviews, the precise format will depend upon the features of the case. This outline will be most relevant to abuse or neglect which has taken place in a family setting.
In all cases, the LSCB overview report should contain an executive summary that will be made public.
This should include as a minimum:
information about the review process
key issues arising from the case
the recommendations that have been made.
The content will need to be suitably anonymas in order to protect the confidentiality of relevant family members and others.
On receiving an overview report the LSCB should:
ensure that contributing agencies 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 endorsed and signed up to at a senior level by each of the agencies involved. The plan should set out by what means improvements in practice/systems will be monitored and reviewed;
the points in the action plan should be prioritised in terms of impact upon practice compared to cost of implementation, be achievable and realistic;
clarify to whom the report, or any part of it, should be made available;
disseminate report or key findings to interests as agreed, make arrangements to provide feedback and de-briefing to staff, family members of the subject child, and the media, as appropriate;
provide a copy of the overview report, executive summary, action plan, integrated chronology and individual management reports to OfSted and a copy of the overview report to the DfES Safeguarding Unit., and make the executive summary available through the LSCB web pages.
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 had been abused in a residential school, it would be 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.
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 measure to ensure that other children are safe; and review, i.e. learning lessons from the case to lessen the likelihood 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.
LSCBs will need to consider carefully who might have an interest in reviews - e.g. the coroner, the CPS, 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 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;
constraints on sharing information when criminal proceedings are outstanding, in that access to the contents of information may not be within the control of the LSCB.
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 debriefing family members, or for responding to media interest about a case, in liaison with the LSCB, contributing agencies and professionals.
The LSCB should ensure that the SHA and the OfSted are briefed, so that they can work jointly to ensure that the Department of Health and the Department for Education and Skills respectively are fully briefed in advance about the publication of the executive summary.
South West LSCBs recognises that Case Reviews are likely to be of little value unless lessons are learned from them. The following will be relevant in helping that maximum benefit is gained from the review process.
The review should be conducted, as far a possible, in such a way that the process is a learning exercise in itself, rather than a trial or ordeal;
Consideration should be given to what information needs to be disseminated, how and to whom, in the light of a review. Examples of both good practice and areas where change is required should be communicated.
Recommendations should focus on a small number of key areas, with specific and achievable proposals for change and intended outcomes.
PCTs should seek feedback from SHAs, who should use it to inform their performance management role.
The role of training and staff development should be identified in all reports.
The LSCB should carefully audit action against recommendations and intended outcomes.
Feedback on review reports should be sought from OfSted and this should be shared and followed up as indicated. OfSted still use reports to inform inspections and performance management.
The DfES is responsible for identifying and disseminating common themes and trends across review reports, and acting on lessons for policy and practice. Thy will commission overview reports at least every two years, drawing on key findings of serious case reviews and their implications for policy and practice.
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 be prepared according to the format and guidelines provided by the LSCB.
Names should be suitably anonymised throughout as outlined within the guidelines.
There should be a brief summary of:
the decisions reached
the services offered and/or provided to the child(ren) and family
other action taken.
Consider the events that occurred, the decisions made, and the actions taken or not. Where judgements were made, or actions taken that indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. Consider specifically;
Were practitioners sensitive to the needs of the children in their work, knowledgeable about potential indicators of abuse or neglect, and about what to do if they had concerns about a child?
Did the organisation have in place policies and procedures for safeguarding children and acting on concerns about the 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 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 of the child and family? (Article 14).
Were more senior managers, or other organisations and professionals, involved at points where they should have been?
Was the work in this case consistent with the organisation and LSCB policy and procedures for safeguarding children, and wider professional standards?
Are there lessons from this case for the way in which this organisation works to safeguard children and promote their welfare? 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 partnership with other organisations; resources?
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?
Serious Case Review: Jill Bloggs, dob (--/--/--)
Individual Management Review Organisation
Case Details
Jill was found dead on 12/1/-- at 12 The Street, South West.
She was accommodated in temporary accommodation under the provisions of the homelessness legislation in November 20--.
At the time of Jill's death her family home was at 13 The Road where her mother, father and younger brother resided.
Family Members:
Jill Bloggs d.o.b. 26.6.-- subject white british
Andrew Bloggs d.o.b. 21.1.-- brother white british
Barbara Bloggs d.o.b. 05.5.-- mother white british
Craig Bloggs d.o.b. 09.7.-- father white british
Nature of incident/circumstances leading to decision to hold Serious Case Review
The reasons for undertaking this review are that
Jill's death gives rise to concerns about the degree to which neglect, by her parents and/or by services, may have been a factor.
The case gives rise to concerns about inter-agency working to protect children.
(detail taken from terms of reference as drawn up by panel)
Scope of Management Review
The review will consider the period between April 1999 and 12 January 20--. It will include information on Jill's brother.
Conduct of Management Review
Summary of Chronology
Key Issues
Lessons learned
Recommendations
Prepared by: (Name)
(Job Title)
Signed: _____________________
Agreed by: (Name)
(Job Title)
Signed: _____________________
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 of LEA, report from adult mental health service). List review panel members and author of overview report.
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 agencies, 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 views and wishes sought or expressed.
Prepare an overview which summaries what relevant information was known to the agencies and professionals involved, about the parents /carers, any perpetrator, and the home circumstances of the children.
This part of the overview should look at how and why events occurred, 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.
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 not be limited to, the recommendations made in individual agency reports.
Recommendations should be:
few in number
focused and specific
capable of being implemented.
If there are lessons to national, as well as local, policy and practice these should also be highlighted.