19. Serious case reviews

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19.1	Introduction
	19.1.1	Focus on the child
	19.1.2	Purpose of a serious case review (SCR)
	19.1.4	Safeguarding siblings and other children
	19.1.6	Reviewing and investigating functions of an LSCB
	19.1.8	When to undertake a SCR
	19.1.12	Deciding which LSCB should take lead responsibility
	19.1.14	Prompting the initiation of a SCR
19.2	Initiating a serious case review
	19.2.1	SCR sub-committee
	19.2.3	Deciding whether a case meets the SCR criteria
	19.2.5	Acting on lessons quickly
	19.2.6	Timescales for initiating and undertaking a SCR
	19.2.12	Notifying the authorities
	19.2.14	Determining the scope and terms of reference of the review
	19.2.19	Serious case review panel
19.3	Individual agency management reviews (IMRs)
	19.3.5	Agency involvement
	19.3.12	Engaging staff
	19.3.14	Scope and format of IMRs
		-	Sample chronology table
	19.3.21	Quality assurance
19.4	LSCB overview report
	19.4.3	Publishing LSCB overview reports
	19.4.6	Suggested format for LSCB overview reports
	19.4.11	SCR panel responsibilities for the overview report
	19.4.12	Executive summary
	19.4.19	LSCB action on receiving the SCR report
	19.4.23	Audit and monitoring
19.5	Reviewing institutional abuse
19.6	Public accountability and confidence
	19.6.4	Learning lessons locally
	19.6.7	Learning lessons regionally and nationally
19.7	Overview of SCR process flowchart

19.1

Serious case reviews

Introduction

Serious case reviews are undertaken in order for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. The London Serious Case Review (SCR) Toolkit available at www.londonscb.gov.uk/ provides supplementary guidance to these Procedures to support a consistent and effective approach by LSCBs to undertaking and learning from a serious case review.

Focus on the child

19.1.1

It is essential, to maximise the quality of learning, that the child's daily life experiences and an understanding of his or her welfare, wishes and feelings are at the centre of the serious case review, irrespective of whether the child died or was seriously harmed. This perspective should inform the scope and terms of reference of the serious case review as well as the ways in which the information is presented and addressed at all stages of the process, including the conclusions and recommendations.

Purpose of a serious case review (SCR)

19.1.2

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 intra- and inter-agency working and better safeguard and promote the welfare of children.

19.1.2

Serious case reviews are not inquiries into how a child died or was seriously harmed, or who is culpable; that is a matter for coroners and criminal courts respectively to determine, as appropriate.

19.1.3

Serious case reviews are also not part of any disciplinary inquiry or process relating to individual practitioners. Where information emerges in the course of a serious case review indicating that disciplinary action should be initiated under established procedures, the relevant processes should be undertaken separately from the serious case review process. Alternatively, some serious case reviews may be conducted concurrently with (but separately from) disciplinary action. In some cases (for example, alleged institutional abuse) it may be necessary to initiate disciplinary action as a matter of urgency to safeguard and promote the welfare of other children.

Safeguarding siblings or other children

19.1.4

When a child dies or is seriously harmed, and abuse or neglect is known or suspected to be a factor, local organisations should immediately ascertain whether there are other children who are suffering, or likely to suffer, significant harm and who require safeguarding e.g. siblings or other children in an institution or social network (including ICT) within which abuse is alleged.

19.1.5

Where there are concerns about the welfare of siblings or other children the guidance in section 6. referral and assessment should be followed. See also section 14. Organised and complex abuse as appropriate.

Reviewing and investigative functions of LSCBs

19.1.6

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006- [The Local Safeguarding Children Boards Regulations 2006, Statutory Instrument no. 2006/90] - requires LSCBs to undertake reviews of serious cases. They should be undertaken in accordance with the processes set out in this chapter. The same criteria apply to all children, including those with a disability - [Safeguarding Disabled Children: Practice guidance (2009). London: Department for Children, Schools and Families].

19.1.7

Regulation 5 sets out that:

(1)

The functions of a LSCB in relation to its objective (as defined in section 14(1) of the Act are as follows -

(e)

undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

(2)

For the purposes of paragraph (1) (e) a serious case review is one where -

(a)

abuse or neglect of a child is known or suspected; and

(b)

either -

(i)

the child has died; or

(ii)

the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

When to undertake a SCR

19.1.8

When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a serious case review into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children's social care is, or has been, involved with the child or family.

19.1.9

A serious case review should also always be carried out when a child dies in custody, either in police custody, on remand or following sentencing, in a Youth Offending Institution (YOI) or a Secure Training Centre (STC), or where the child was detained under the Mental Health Act 2005.

19.1.10

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 seriously harmed as a result of being subjected to sexual abuse; or
Whose parent has been murdered and a homicide review is being initiated under the Domestic Violence, Crime and Victims Act 2004; or
Who has been killed by a parent with a mental illness; or
* Who has been seriously harmed following a violent assault perpetrated by another child or an adult;

and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. This includes inter-agency and/or inter-disciplinary working.

19.1.11

The following questions may also help in deciding whether a case should be the subject of a serious case review. The answer 'yes' to one or more of these questions is likely to indicate that a serious case review could yield useful lessons:

Was there clear evidence of a child having suffered, or been likely to suffer, significant harm that was:
- not recognised by organisations or professionals in contact with the child or perpetrator or
- not shared with others or
- not acted on appropriately?
Was the child abused or neglected in an institutional setting (for example, school, nursery, children's or family centre, YOI, STC, immigration removal centre, mother and baby unit in a prison, children's home or Armed Services training establishment)?
Was the child abused or neglected while being looked after by the local authority?
Was the child a member of a family that has recently moved to the UK, for example as asylum seekers or temporary workers?
Did the child suffer harm during an unauthorised absence from an institution, or having run away from home or other care setting?
Does one or more agency or professional consider that its concerns about a child's welfare were not taken sufficiently seriously, or acted on appropriately, by another?
Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding children procedures which go beyond the handling of this case?
Was the child the subject of a child protection plan at the time of the incident, or had they previously been the subject of a plan or on the child protection register?
Does the case appear to have implications for a range of agencies and/or professionals?
Does the case suggest that the LSCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately promulgated, understood or acted on?
Are there any indications that the circumstances of the case may have national implications for systems or processes, or that it is in the public interest to undertake a serious case review?

Deciding which LSCB should take lead responsibility

19.1.12

Where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is / was normally resident (the 'home authority'; see section 11.9.2 Definition of 'home' and 'host' authority.) 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.

19.1.13

In the case of looked after children, the local authority looking after the child ('the host' authority' see section 11.9.2 Definition of 'home' and 'host' authority.) should take lead responsibility for conducting the review, again involving other LSCBs with an interest or involvement.

Prompting the initiation of a serious case review

19.1.14

Any professional may refer a case to the LSCB that appears to meet the criteria in 19.1.8 to 19.1.11, above and which he or she considers is likely to have important lessons for inter-agency working. The professional should notify the Chair of the LSCB, and confirm in writing. In addition, the Secretary of State for the Department for Education has powers to demand an inquiry be held under the Inquiries Act 2005.

19.1.15

The LSCB Chair has ultimate responsibility for deciding whether to conduct a serious case review.

19.2

Initiating a serious case review

SCR sub-committee

19.2.1

Many LSCBs have a standing SCR sub-committee to oversee and quality assure all serious case reviews undertaken by the LSCB, and to provide advice to the LSCB Chair on whether the criteria for conducting a serious case review have been met.

19.2.2

A SCR sub-committee should be chaired by an experienced person who could be the independent Chair of the LSCB, or a member of the LSCB. As a minimum the sub-committee should involve representatives from:

LA children's social care, health (commissioning Primary Care Trust and other partners as relevant);
Education; and
The police.

Members of agencies who have responsibilities for completing individual management reviews may be members of the serious case review sub-committee but it should not consist solely of such people.

Deciding whether a case meets the SCR criteria

19.2.3

In considering whether a case meets the threshold for a serious case review the LSCB Chair should take written advice from the serious case review sub-committee. Where the child has died, the LSCB Chair should also use information available from the professionals involved in reviewing the child's death (see section 12 Unexpected death of a child) to assist in making this decision.

19.2.4

The LSCB Chair can advise an agency or agencies to conduct: a single individual management review, e.g:

A single Individual management review, where there are lessons to be learned about the way in which staff worked within one agency rather than about how agencies worked together; or
A smaller scale audit of an individual case that gives rise to concern but does not meet the criteria for a serious case review.

For the latter, agencies should consider using methodologies such as those developed by the Social Care Institute for Excellence (SCIE) - [Fish S., Munro E. and Bairstow S. (2008) SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews. London: Social Care Institute for Excellence.] - or root cause analysis used in the health service. Arrangements should be made to share relevant findings with the serious case review sub-committee or serious case review panel.

Acting on lessons quickly

19.2.5

In all cases, as soon as lessons are able to be identified they should be acted upon without necessarily waiting for a decision to instigate a serious case review or for the review to commence or be completed.

Timescales for initiating and undertaking a SCR

19.2.6

Within one month of a case coming to the attention of the LSCB Chair, he or she should decide, following a recommendation from the serious case review sub-committee, whether to initiate a serious case review. See section 19.7 Overview of SCR process flowchart.

19.2.7

Serious case reviews should be completed within six months from the date of the decision to proceed. If a serious case review cannot be completed within six months of the LSCB Chair's decision to initiate it (perhaps because of judicial proceedings), the LSCB should revise its timetable.

19.2.8

Where an extension beyond the six month timeframe is necessary, the LSCB should:

Produce an update on progress and a revised project plan, which must include:
- recommendations for action where these are not dependent on the serious case review being concluded until after other proceedings have ended;
- actions taken to date;
- an explanation for the extension to the timescale; and
- the revised completion date.
Inform Ofsted and keep Ofsted fully appraised of timing expectations, of risks of delay and of interdependencies with other parallel or related processes.

19.2.9

In some cases, criminal proceedings may follow the death or serious injury of a child. The Chair of the serious case review panel should discuss with the relevant criminal justice agencies such as the police and the CPS, at an early stage, how the review process should take account of such proceedings. For example, how does this affect timing and the way in which the serious case review is conducted (including any interviews of relevant personnel), what is its potential impact on criminal investigations, and who should contribute at what stage? Much useful work to understand and learn from the case can often proceed without risk of contamination of witnesses in criminal proceedings. In some cases it may not be possible to finalise the individual management reviews and the overview report or to finalise and publish an executive summary until after coronial or criminal proceedings have been concluded, but this should not prevent early lessons learned from being acted upon.

19.2.10

Serious case reviews should not be delayed as a matter of course because of outstanding family, civil or administrative court cases. The LSCB Chair should make these decisions on a case by case basis based on advice from the Chair of the serious case review panel and having consulted with the local authority where there are pending family cases. The LSCB Chair may also need to seek legal advice to assist in deciding how to proceed.

19.2.11

The final serious case review report, including the executive summary, should take full account of salient, new information which becomes available during the course of these proceedings and the facts, conclusions and recommendations should be revised accordingly.

Notifying the authorities

19.2.12

The LSCB Chair should notify the Department for Education (DfE) and Ofsted whether or not a serious case review will be initiated as soon as the decision is made. PCT commissioners should ensure their Strategic Health Authority (SHA) and the Care Quality Commission (CQC) are notified. The police should also notify Her Majesty's Inspectorate of Constabulary (HMIC) and similarly the National Offender Management Service should notify Her Majesty's Inspectorate of Prisons (HMIP) and Her Majesty's Inspectorate of Probation (HMI Probation).

19.2.13

In all cases and at all stages in the serious case review process from the first notification to Ofsted of a serious incident to the completion of the final serious case review report, information relating to children, family members and professionals involved in the case (with the exception of the LSCB Chair, serious case review panel Chair and the overview report author) should be anonymised by the LSCB before being submitted to any external organisation or body (including the DfE and Ofsted).

Determining the scope and terms of reference of a SCR

19.2.14

If the serious case review sub-committee advises that a serious case review should take place, they must also recommend the scope and terms of reference for the review.

19.2.15

The initial scoping of the serious case review should take into account current information known in each case and must identify those who should contribute. As further information becomes available other contributors may be needed e.g. specialist adult service providers.

19.2.16

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 serious case review start, and by what date should it be completed, bearing in mind the timescales for completion set out below? Are there any relevant court cases or investigations pending which could influence progress or the timing of the publication of the executive summary?
Over what time period should events in the child's life be reviewed, i.e. how far back should enquiries extend and what is the cut-off point? What family history/background information will help better to understand the recent past and the present?
How should the child (where the review does not involve a death), surviving siblings, parents or other family members contribute to the serious case review, and who should be responsible for facilitating their involvement? How will they be involved and contribute throughout the overall process?
Are there any specific considerations around ethnicity, religion, diversity or equalities issues that may require special consideration?
Did the family's immigration status have an impact on the child/children or on the parents' capacities to meet their needs?
Which organisations and professionals should be asked to submit reports or otherwise contribute to the serious case review 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 third sector organisations? Is there a need to involve organisations/professionals working in other LSCB areas and what should be the respective roles and responsibilities of the different LSCBs with an interest?
Will the LSCB need to obtain independent legal advice about any aspect of the proposed serious case review?
Who should be appointed as the independent author for the overview report (bearing in mind that this person should not be the Chair of the LSCB, the serious case review sub-committee or the serious case review panel).
Might it help the serious case review panel to bring in an outside expert at any stage, to help understand crucial aspects of the case?
Will the case give rise to other parallel investigations of practice, for example, into the health or adult social care provided or multi-disciplinary suicide reviews, a domestic homicide review where a parent has been killed, a Prisons and Probation Ombudsman (PPO). Fatal Incidents Investigation where the child has died in a custodial setting or a Serious Further Offence (SFO) - [PC 22/2008 (revised Notification and Review Procedures for Serious Further Offences)] - or MAPPA serious case review (MSCR) process where offenders are charged with serious further offences whilst subject to statutory supervision? And if so, how can a co-ordinated or jointly commissioned review process address all the relevant questions that need to be asked in the most effective way and with minimal delay? Arrangements should be agreed locally on how a NHS Serious Untoward Incident investigation into the provision of healthcare should be co-ordinated with a serious case review.
How will the serious case review 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 Crown Prosecution Service (CPS) and to ensure that relevant information can be shared without incurring significant delay in the review process?
How should the review process take account of relevant lessons learned from research (including the biennial overview reports of serious case reviews) and from serious case reviews which have been undertaken by the LSCB?
How should any family, public and media interest be managed before, during and after the serious case review? In particular, how should surviving children (where appropriate given their age and understanding) and family members be informed of the findings of the serious case review?

19.2.17

The LSCB Chair should ensure that the terms of reference address the key issues in the case and approve them. Where necessary LSCBs should seek their own legal advice.

19.2.18

Some of these issues may need to be revisited by the serious case review panel as the review progresses and new information emerges e.g. through a criminal investigation or a child death review in accordance with section 10. Unexpected death of a child. This may require the terms of reference to be revised and agreed by the LSCB Chair.

SCR review panel

19.2.16

Following a decision by the LSCB Chair to undertake a serious case review, the serious case review sub-committee should commission a serious case review panel to manage the process.

19.2.17

Where a LSCB does not have a standing serious case review sub-committee, a serious case review panel should be convened by the LSCB to advise the LSCB Chair on whether the criteria for undertaking a serious case review have been met and, where appropriate, to ensure the serious case review is undertaken in accordance with this guidance. In such circumstances the same membership requirements apply to a serious case review panel as set out in paragraph 19.2.16 for a serious case review sub-committee.

19.2.18

The Chair of any serious case review panel should not be a member of the LSCB/s involved in the serious case review, an employee of any of the agencies involved in the serious case review or the overview report author. The serious case review panel Chair can be the independent LSCB Chair, someone from another LSCB which is not involved in the serious case review or from an agency which is not involved in the case.

19.3

Individual management reviews

19.3.1

As soon as a decision is taken to proceed with a serious case review each relevant service should undertake an individual management review of its involvement with the child and family.

19.3.2

If a case gives rise to concerns within the individual organisation the organisation should not wait for the decision to initiate a serious case review before start an individual management review.

19.3.3

The aim of an individual management review is:

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.

19.3.4

The aim of management reviews should be achieved through:

Establishing a factual chronology of the action which has been taken within the agency;
Analysing the involvement of the agency;
Identifying what lessons may be learned from the case about the way in which the agency works to safeguard children and promote their welfare;
Recommending appropriate action in the light of the identified lessons. This should include the intended outcomes and an expectation that the agency will review whether these have been achieved.

Agency involvement

19.3.5

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 serious case review 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.

Independent consultants

19.3.6

Where independent professionals have been involved with the case, they should contribute reports of their involvement.

Cafcass

19.3.7

Where Cafcass contributes to a review, the prior agreement of the courts should be sought so that the duty of confidentiality which the children's guardian has under the court rules can be waived to the degree necessary.

Police

19.3.8

The police may be restricted in the amount of information they can provide for the serious case review during the process of criminal investigation. Information collected by the police may be subject to rules of disclosure for court proceedings.

Health services

19.3.9

Designated safeguarding health professionals, on behalf of the PCT/s as commissioners, should review and evaluate the practice of all involved health professionals, including GPs and providers commissioned by the PCT area. Where more than one PCT has commissioned services the PCTs will need to agree locally how they will work together. This may involve reviewing the involvement of individual practitioners and NHS Trusts, and advising named professionals and managers who are compiling reports for the review. The designated professionals should produce an integrated health chronology and a health overview report focusing on how health organisations have interacted together. This may generate additional recommendations for health organisations. The health overview report will constitute the individual management review for the PCTs as commissioners. Designated safeguarding health professionals also have an important role in providing guidance on how to balance confidentiality and disclosure issues to ensure an objective, just and thorough approach to identifying lessons in the individual management review. If the designated health professional/s have been clinically involved with the case the PCT should seek advice and help from another PCT designated professional as necessary.

19.3.10

The process of conducting an individual management review requires access to records relevant to the child such as those from health bodies. The public interest served by this process warrants full disclosure of all relevant information within the child's own records. In some circumstances the person conducting the individual management review may require access to information about third parties (for example, members of the child's immediate family or carers) that is either contained within the child's health records or in the health records of another person. While in most cases there will be a public interest in disclosing this information, the record holder/s should ensure that any information they disclose about a third party is both necessary and proportionate. All disclosures of information about third parties need to be considered on a case by case basis, and the reasoning for either disclosure or non-disclosure should be fully documented. This applies to all records of NHS-commissioned care, whether provided under the NHS or in the independent or third sector.

Custodial services

19.3.11

Where a child dies in or whilst under escort to or from a custodial setting such as a YOI or STC, the PPO will conduct a fatal incidents investigation and report on the circumstances surrounding the death of that child. The investigation will examine the child's period in custody and assess the clinical care they received as well as examining relevant factors which led to the child being placed in custody. In such cases a representative of the Youth Justice Board (YJB) should be a member of the serious case review panel to help ensure that relevant youth justice issues are covered. The PPO may be invited to attend serious case review panel meetings for specific, agreed purposes. The serious case review terms of reference should set out how the PPO, the serious case review panel and the serious case review sub-committee will work together to share relevant information during the process of undertaking the serious case review - [The DfE and PPO are agreeing a memorandum which will set out in more detail how LSCBs and the PPO relate to each other when a fatal incidents investigation is being undertaken by the PPO and a SCR is being undertaken by a LSCB/s with respect to the same child]

Engaging staff

19.3.12

Where staff or others are interviewed by those preparing individual management reviews, a written record of such interviews should be made and this should be shared with the relevant interviewee. If the review finds that policies and procedures have not been followed, relevant staff or managers should be interviewed in order to understand the reasons for this.

19.3.13

On completion of each individual management review 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 serious case review report has been completed and before the executive summary is published. It is important that the serious case review 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.

Scope and format of IMRs

19.3.14

The following outline format should guide the preparation of individual management reviews to help prepare an overview report. The questions posed do not comprise a comprehensive checklist relevant to all situations. Each case may give rise to specific questions or issues that need to be explored, and each serious case review should consider carefully the circumstances of individual cases and how best to structure the serious case review in the light of the particular circumstances.

What was our involvement with this child and family?

19.3.15

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.

Sample Chronology Table

Date	Source of Information	Family Contact - Child	Family Contact - Adult	Communication - within agency	Communication - external to agency	Response or Outcome	Comments

19.3.16

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.

Analysis of involvement

19.3.17

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 specifically 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 LSCB's policy and procedures for safeguarding and promoting the welfare of children, 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?

19.3.18

Was there sufficient management accountability for decision making?

What do we learn from this case?

19.3.19

The following questions should be answered:

Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children?
Is there good practice to highlight, as well as ways in which practice can be improved?
Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources?
Are there implications for current policy and practice?

Recommendations for action

19.3.20

The following questions should be answered:

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?

Quality assurance

19.3.21

The individual management review reports should be quality assured by the senior officer in the agency which has commissioned the report and when they are satisfied the findings should be accepted by the agency. This senior officer will be responsible also for ensuring that the recommendations of the individual management review, and where appropriate the overview report, are acted on. To facilitate this, each LSCB agency should have clear procedures on the conduct of management reviews.

19.4

LSCB overview report

19.4.1

The serious case review panel is responsible for producing a composite overview report for the LSCB. It should be commissioned from a person who is independent of all the agencies / professionals involved.

19.4.2

The overview report should enable professionals from all relevant sectors to understand fully what happened in each case - the context in which the events occurred - and to learn and apply the lessons. The overview report should bring together the facts, analyses the findings of the internal management and other reports and makes recommendations for future action.

Publishing overview reports and executive summaries

19.4.3

The overview report and the executive summary of all serious case reviews completed after 10th June 2010 must be published. The presumption is that all SCRs will be published, anonymised and without identifying details, unless there are compelling reasons relating to the welfare any surviving children directly concerned in the case for this not to happen.

19.4.4

There is an important balance to be struck between transparency and openness and the protection and welfare of individuals and their siblings. This means preparing the SCR overview report in a form suitable for publication, or redacting it appropriately before publication in order to protect the identity of children, relevant family members and others, and comply with the Data Protection Act 1998 when published.

LSCBS should also be mindful of other restrictions on publication of information e.g. Court orders and constraints on public information sharing when criminal proceedings are outstanding, and should take independent advice if there is any doubt about compliance with the law.

19.4.5

The internal management reviews should not be made publicly available.

Suggested format for LSCB overview report

19.4.6

Overview reports should be produced according to the following outline format although, as with management reviews, the precise format will depend upon the features of the case. This outline will be most relevant to abuse or neglect which has taken place in a family setting (a review is likely to be more complex for abuse in an institutional setting or complex situation).

19.4.7

The introduction should:

Summarise the circumstances that led to a serious case review being undertaken in this case.
State the terms of reference of the review.
Record the methodology used including the documents reviewed, and whether the information was provided in an interview or through written evidence.
List agencies or types of contributors to review and the nature of their contributions (for example, individual management review by local authority, report through the PCT as commissioner from adult mental health service). List the names and roles/positions/job titles of the LSCB Chair, serious case review panel Chair, the author of the overview report and the job titles and employing organisations of all the serious case review panel members.
List external investigations, if any, that are being conducted (e.g. a Probation and Prisons Ombudsman investigation following the death of a child in custody or a mental health inquiry).

19.4.8

There should be a section providing facts which has:

An anonymised genogram showing membership of family, extended family and household; and
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;
Explicitly consideration of 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; and
A summary of 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.

19.4.9

There should be a section providing an analysis of 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 serious case review should be considered alongside learning from previous serious case reviews undertaken by the LSCB and findings from relevant research.

19.4.10

There should be a conclusions and recommendations section summarising 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. If there are lessons for national as well as local policy and practice, these should also be highlighted and the information sent to the relevant government department.

SCR panel responsibilities for the overview report

19.4.11

The serious case review panel should:

Ensure that it actively manages the serious case review 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 serious case review report;
Identify any urgent action arising from the serious case review which requires immediate action and notify the LSCB Chair in order for action to be taken;
Ensure efficient compilation of the multi-agency chronology (which forms part of the LSCB overview report). The panel should use the chronology to identify any discrepancies between agency reports, and notify the LSCB Chair so that they can be clarified with the agencies;
Consider the individual management reviews reports and ensure that contributing agencies 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. Including deciding:
- whether the overview report should be prepared in a form suitable for publication in anonymised form and not containing any identifying details, or
- whether the report will be redacted appropriately before publication (see 19.4.3 and 19.4.4, above)
Ensuring that the executive summary and the overview report are properly prepared for publication - accurately representing the full serious case review, including the action plan in full and being fully anonymised / redacted (see 19.4.3 and 19.4.4, above). The report should, however, include the names of the LSCB Chair, serious case review panel Chair, the overview report author, and the job titles and employing organisations of all the serious case review panel members.;
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;
Clarify to whom, in which agencies, attention should be drawn to the executive summary, overview report and action plan to support implementation of the recommendations and the learning of the lessons; and
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 executive summary and overview report.

Executive summary

19.4.12

In all cases, the serious case review overview report and the individual management reviews should be used to produce an executive summary which accurately reflects the full overview report. The executive summary should include information about the review process, key issues arising from the case, the recommendations and the action plan (including any actions that have been completed). The content of the executive summary needs to be suitably anonymised (see 19.4.3 and 19.4.4, above). The executive summary should, however, include the names of the LSCB Chair, serious case review panel Chair, the overview report author, and the job titles and employing organisations of all the serious case review panel members.

19.4.13

Executive summaries should be produced according to the following outline format although, as with individual management reviews and overview reports, the precise format will depend on the features of the case:

19.4.14

Introduction:

Summarise the circumstances that led to a serious case review being undertaken in this case and the process followed by the review.
List the names of the LSCB Chair, serious case review panel Chair and the author of the overview report, and the job titles and employing organisations of all serious case review panel members.
Note the parallel processes, where relevant, that are being or have been conducted and how they have interrelated with the processes followed by the review (e.g. criminal proceedings, PPO investigation following the death of a child in custody, or independent investigation of adverse events in mental health services).
Note the extent to which the family (and the child, where he or she has been seriously harmed) have been involved in the review.

19.4.15

The facts/summary of events:

Summarise the key facts of the case and the sequence of events. This should be an accurate précis of circumstances of the child and their family and of the chronology of the involvement of the relevant agencies. The narrative should be consistent with the detailed chronology in the full overview report.
Care should however be taken to ensure that the summary is appropriately anonymised and sensitive to the child and family in respect of information that will be available in the public domain.

19.4.16

Key issues or themes arising from the case

Summarise the key issues or themes arising from the analysis in the overview report, and highlight the key decisions taken in respect of the child and their family and the opportunities for early intervention where they existed. With hindsight could or should different decisions or actions have been taken at the time?

19.4.17

Priorities for learning and change

Describe clearly the conclusions and lessons learned from the review, both for individual agencies and for inter-agency working through the LSCB and the
Children's Trust Board, ensuring these are in the context of the issues or themes that arose from the case.
Identify examples of good practice as well as being clear where systems should improve.

19.4.18

Recommendations and action plan

Reproduce the recommendations and action plan from the full SCR.
The action plan should highlight which recommendations are relevant to which agencies, the agency/ies responsible for taking forward specific recommendations, how action will be monitored and by whom. It should also set out the progress that has already been made in implementing or completing recommendations and plans to evaluate the impact of these changes.

LSCB action on receiving the SCR report

19.4.19

The serious case review sub-committee, on behalf of the LSCB, should quality assure the final serious case review - that is, the individual management reviews reports, the overview report, the executive summary and the action plan.

19.4.20

The LSCB should approve the final serious case review and:

Provide an anonymised copy of the individual management reviews, overview report, executive summary and the individual and multi-agency action plans and chronologies to Ofsted, the SHA and DfE. All personal information relating to children, family members and professionals involved in the case (with the exception of the names of the LSCB and serious case review panel Chair and the overview report author) should be anonymised in all the serious case review documentation submitted to Ofsted. If the child died in a custodial setting, copies of the anonymised serious case review should be made available to the YJB and copies of the anonymised overview report and executive summary should be provided to the PPO;
Make arrangements to provide feedback and debriefing to staff and the media as appropriate;
Disseminate the overview report and/or the executive summary and key findings to relevant interested parties;
Publish the serious case review overview report and executive summary once the serious case review has been completed (see 19.4.3 and 19.4.4 above);
Implement those actions for which the LSCB has lead responsibility and monitor the timely implementation of the serious case review action plan;
On receipt of the evaluation letter from Ofsted, take action as necessary to amend the action plan and/or the serious case review report if the serious case review executive summary has been published before receiving Ofsted's feedback; and
Formally conclude the review process when the action plan has been implemented.

19.4.21

The LSCB should decide on a case by case basis when to publish the overview report and the executive summary. This decision should take account of the timing of the conclusion of relevant court cases and statutory processes such as inquests or a Probation and Prisons Ombudsman investigation. The LSCB, on advice from the serious case review panel and where relevant the CPS, the police or its lawyers, should decide whether new information may become available from these other processes which is likely to have an impact on the lessons to be learnt from the serious case review. If the findings are not likely to have an impact, then there should be no delay in publishing the serious case review executive summary. On the other hand, in some cases it may be best to undertake the individual management reviews and finalise them and the serious case review overview report in the light of this new information or findings before publication of the serious case review executive summary. In addition, LSCBs may decide to take account of any points raised in Ofsted's evaluation of the serious case review before publishing the serious case review executive summary but, depending on local circumstances, it may be necessary for the LSCB to publish it prior to the completion of an evaluation by Ofsted.

19.4.22

All serious case review s are evaluated by Ofsted and, in line with the arrangements agreed between inspectorates, the evaluation may involve other inspectorates notably the CQC and HMIC. The evaluation will be shared with the LCSB and, together with the published executive summary, with partner inspectorates and government. Where a serious case review has been evaluated as 'inadequate' the LSCB should convene a serious case review panel, to be chaired by an independent person, to reconsider the review. The LSCB is then required to submit to Ofsted, within three months, an action plan that addresses the inadequacies of the serious case review.

Audit and monitoring

19.4.23

Monitoring of the action plan produced from the overview report will be undertaken by the serious case review sub-committee reporting back to LSCB.

19.4.24

Any areas of inter-agency activity identified as of particular concern may also be referred for consideration by the quality assurance sub-committee as a potential area for future audit and research.

19.5

Reviewing institutional abuse

19.5.1

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.

19.5.2

If, for example, 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.

19.5.3

There needs to be clarity over the interface between the different processes of investigation (including criminal investigations); case-management, including help for abused children and immediate measures to ensure that other children are safe; and review (i.e. learning lessons from the case to reduce the chance of such events happening again). The three 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.

19.6

Public accountability and confidence

19.6.1

All serious case review overview reports and executive summaries completed after 10th June 2010 must be published, unless there are compelling reasons not to do so (see 19.4.3 and 19.4.4, above). Publishing is designed to reflect public accountability, promote public confidence and improve transparency in the child protection system.

19.6.2

Following publication LSCBs and partner agencies should anticipate the response from the media and plan in advance how to manage it constructively. A lead agency may take responsibility for de-briefing family members, or for responding to media interest about a case, in liaison with contributing agencies and professionals.

19.6.3

The LSCB should ensure that Ofsted and all other relevant bodies including the SHA, the CQC, HMIC, HMIP and HMI Probation are appropriately briefed in advance about the publication of the overview report and executive summary. Where a child has died in a custodial setting, this briefing should include the YJB and the PPO. The SHA should brief the Department of Health.

Learning lessons locally

19.6.4

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. 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.

19.6.5

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.

19.6.6

The SCR sub-committee should provide information to relevant LSCB/s on the actions taken in response to SCRs which have been completed by the LSCB/s in the previous year. LSCBs will draw on this information when publishing their annual reports. Appropriate care should be taken to ensure confidentiality of personal information and sensitivity to the families whose child is the subject of a SCR. The LSCB annual report should support the driving forward of measures to prevent child deaths and serious harm where abuse and neglect have been factors and to safeguard and promote the welfare of children.

Learning lessons regionally and nationally

19.6.7

Taken together, child death and serious case reviews should be an important source of information to inform national policy and practice.

19.6.8

The London Safeguarding Children Board is in a position to identify and disseminate common themes and trends across London review reports, and support London LSCBs to act on lessons for policy and practice. The London Safeguarding Children Board undertakes this activity in collaboration with London LSCBs.

19.6.9

The DfE is responsible for identifying and disseminating common themes and trends across review reports, and acting on lessons for policy and practice. The DfE commissions regular reports, drawing out key findings of SCRs and their implications for policy and practice to assist the process of learning lessons. In the future relevant findings from the work of the local child death overview teams will be integrated into these reports.

19.6.10

Professionals may also wish to refer to Working Together to Safeguard Children (DCSF, 2010) chapter 8, which contains additional information and may assist.

19.7

Overview of SCR process flowchart