8.1 The Local Safeguarding Children Board Regulation number five states that one of the functions of the LSCB is to undertake reviews of serious cases and advise the Children’s Services Authority and their Board partners on lessons to be learned. This chapter sets out the procedures to be followed in such circumstances.

8.2 It is important to note that the same criteria and procedures apply to both children with or without disabilities. Care should be taken to avoid automatically labelling the death of a child with disabilities as being a consequence of their impairment without due consideration of all the circumstances and context within which the death occurred.

[ The local Safeguarding Children Board Regulations 2006 Statutory instrument 2009 no. 90 ]

Action following the death of a child

8.3 Action following all child deaths should be in accordance with the LSCB child death review process. Separate procedures will be issued in relation to this prior to April 2008 when all LSCBs will be required to establish a Child Death Overview Panel.

8.4 When a child dies and abuse or neglect are known or suspected the first priority must be to consider whether there are other children at risk of harm who may need safeguarding. Anyone who has concerns about the safety of children in such circumstances should immediately contact the local referral point within Children’s Social Care.

8.5 Any professional who suspected that abuse or neglect may have been the cause of a child’s death should:

• Refer to Children’s Social Care
• Inform the chair of the LSCB

Criteria for conducting serious case reviews

8.6 The LSCB should always conduct a serious case review when a child has died and abuse or neglect are known or suspected to be a factor in the child’s death. This is irrespective of where Children’s Social Care have been involved with the child and family

8.7 LSCBs should always consider whether a serious case review should be conducted ;

• Where a child sustains a potentially life threatening injury or serious impairment of health or 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
• The child has been killed by a parent with mental illness,  and
• The case gives rise to concerns about inter-agency working to protect children from harm

8.8 The criteria for a serious case review will have been met where any of the  situations set out in 8.7 have occurred and the case gives rise to concerns about the way in which professionals and services work together to safeguard and promote the welfare of children

The Purpose of Serious Case Reviews

8.9 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;
• As a consequence to improve inter-agency working and better safeguard and promote the welfare of children.

8.10 Serious case reviews are not inquiries into how a child died or who is culpable; that is a matter for the Coroners and Criminal courts respectively to determine, as appropriate. 

Instigating Serious Case Reviews

8.11 Where more than one LSCB has knowledge of a child, the area in which the child is/was normally resident should take lead responsibility for conducting the review.

8.12 Any professional may refer a case which they believe meets the above criteria to the chair of the LSCB. In addition, the Secretary of State for the Department for Education and Skills has powers to demand an inquiry to be held under the Inquiries Act 2005.

8.13 The LSCB should establish a Serious Cases Review Panel (SCRP) involving at least Children’s Social Care, Health, Education and the Police to consider whether the criteria for a serious case review should take place. This panel should include at least one representative from any other LSCBs who have an interest in the case and any other professionals who may have particular expertise to contribute e.g. representatives from adult services.

8.14 If the Serious Case Review Panel finds that the criteria for conducting a review have been met, the chair of the panel should forward this as a recommendation to the chair of the LSCB who has ultimate responsibility for deciding whether or not to conduct a serious case review.

8.15 When a case does not reach the criteria for a full serious case review the panel should consider whether individual management reviews should be requested, or the case referred to the LSCB audit group. In these situations arrangements should be made to share findings with the SCRP.

8.16 The decision whether or not to hold a Serious Case Review must be made within one month of the case coming to the attention of the LSCB Chair

The Serious Case Review Process

8.17 Once the LSCB chair has decided that a review should take place:

• The local region of the Commission for Social Care Inspection should be informed
• The PCT should inform its SHA.
• All agencies who have had contact with the family (including relevant independent professionals such as GPs and voluntary and private organisations) should be informed by the LSCB Chair and asked to secure their records immediately

8.18 Where criminal proceedings have also been instigated or are likely, the LSCB Chair or the Chair of the Serious Case Review Panel should immediately discuss with the relevant criminal justice organisations how the review process should take account of such proceedings. For example, how does this affect timing, the way in which the review is conducted (including interviews with relevant staff), its potential impact on criminal investigations and who should contribute at what stage? Serious Case reviews should not be delayed as a matter of course because of outstanding criminal proceedings or an outstanding decision on whether or not to prosecute.

8.19 The Serious Case Review Panel should meet and consider the scope of the review process. The following should be considered.

• The most important issues to address in this case
• Over what time period events 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 understand the recent past and present?
• How the relevant information can be obtained and analysed
• Whether other LSCB areas with an interest in the case have been informed and what the respective roles and responsibilities of the different LSCBs should be.
• Which organisations and professionals should contribute to the review through submitting individual management reviews?
• Where organisations are involved who are outside the main statutory agencies, who should make the link with them and what contribution should be requested?
• Who should be appointed as the independent author for the overview report? The author must be independent of all the agencies/professionals involved.
• How family members might contribute to the review and who should be responsible for facilitating their involvement?
• Whether any part of the review should involve or be conducted by a party independent of the professionals/ organisations who will be required to participate in the review.
• Whether an outside expert should be co-opted onto the panel at any stage to shed light on crucial aspects of the case
• Whether the LSCB needs to obtain any independent legal advice about any aspect of the proposed review/
• Whether the case will give rise to other parallel investigations into practice, for example, 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 a child has died in a custodial setting
• Where parallel investigations will take place how a co-ordinated or jointly commissioned review process could best address all the relevant questions in the most economical way.
• How any public, family and media interest should be managed, before, during and after the review?
• How the review process should take account of and liaise with any coroner’s inquiry or any criminal investigations or proceedings related to the case.
• When the review should start and by what date it should be completed. This date should generally be within four months of the decision to hold a review. Any alternative timescale will need to be agreed with the local Commission for Social Care Inspection immediately following the meeting.
• Agree a timescale for further meetings of the Serious Case Review Panel in order to oversee the review process, including receiving individual management reviews and the overview report.

8.20 Following the above meeting, the Chair of the Serious Case Review Panel should inform all relevant agencies that a review is taking place, its Terms of Reference and the timescale for the completion of Individual Management Reviews

8.21 The Chair of the Serious Case Review Panel should ensure that arrangements are in place within each agency to inform all staff who have been involved with the family and offer them appropriate support.

8.22 It is the responsibility of individual agencies to ensure that management reviews are completed within the timescale required by the SCRP and those commissioned to complete the reviews are informed of any requirements to attend meetings of the Serious Case Review Panel.

Individual Management Reviews

8.23 Individual Management Reviews are separate from any disciplinary enquiry or process, although information from the review may indicate that disciplinary action should be taken. In some cases (e.g. alleged institutional abuse) disciplinary action may be needed urgently to safeguard and promote the welfare of other children

8.24 Where a child dies in a custodial setting the Prisons and Probation Ombudsman will investigate the circumstances surrounding the death of the child. The report would normally be made available to assist the serious case review process

8.25 Individual Management Reviews should be commissioned by a senior officer from the relevant agency. It is this senior officer who will be responsible for accepting the findings and ensuring that recommendations are acted upon.

8.26 Individual Management Reviews should not be carried out by anyone who has been directly involved with the child or family or has been the immediate line manager or supervisor of practitioner(s) involved

8.27 The senior officer commissioning the Individual Management Review should ensure that the author:

• Receives a copy of the terms of reference as agreed by the Serious Case Review Panel
• Receives a copy of any template supplied by the Serious Case Review Panel for the purposes of compiling the chronology
• Is clear about the required timescale for the review
• Has access to the records that have been secured

8.28 The IMR author should review the records and compile a chronology of agency involvement.  Following this they should identify which staff should be interviewed and agree this with the senior officer commissioning the report. The senior officer should be responsible for ensuring that the relevant staff are informed and offered appropriate support. Where staff are no longer working for the organisation it is the responsibility of the senior officer to contact them and ask them whether they would wish to be interviewed.

8.29 The criteria for interviewing staff should be:

• They are likely to have substantial background information about the family that may not be apparent from the records, or
• They are likely to be able to assist with an understanding of why events occurred as they did, i.e. supply contextual information, or
• The chronology indicates some good standards of practice and interviews would assist in understanding how this could be replicated in the future, or
• From the chronology it appears that there are concerns about the standard of practice and it is important to give the staff concerned an opportunity to give their point of view

8.30 Where staff are interviewed a written record of such interviews should be made and shared and agreed with the relevant interviewee

8.31 The Individual Management Review should be completed taking account of the practice guidance at the end of this chapter, although the precise format will depend on features of the case. It is important that every report:

• Clearly sets out the history of agency involvement with the family
• Analyses the standard of practice
• Identifies lessons to be learned
• Sets out recommendations for improving practice within the agency concerned

8.32 The Individual Management Review should be submitted to the senior officer who commissioned the report. It is the responsibility of the senior officer to:

• ‘Sign off’ the report and set in motion the steps required to implement the recommendations
• Forward the report to the chair of the Serious Case Review Panel
• Ensure that there is a process in place for feedback and de-briefing for staff involved. This should take place before completion of the overview report by the LSCB. There may also need to be arrangements in place for a follow up feedback session if the LSCB overview report raises new issues for the organisation and staff members.

8.33 It is the responsibility of the Chair of the Serious Case Review Panel:

• To ensure all members of the Serious Case Review Panel and the overview author receive copies of the Individual Management Reviews
• There is a process in place for giving feedback to the authors and requesting further information should this be required.

The LSCB Overview Report

8.34 The Overview Report should bring together, and draw overall conclusions from the information and analysis contained in the individual management reviews and any other relevant reports

8.35 The format of the report will depend upon the precise features of the case. When abuse or neglect has taken place in a family setting the report should follow the format set out in the practice guidance at the end of this chapter.

8.36 All Overview Reports should include;

• An integrated chronology of agency involvement developed from the individual management review chronologies
• An clear outline of agency involvement during the timeframe covered by the review
• An analysis of the standard of practice
• Any lessons that can be learnt about how to improve practice
• Recommendations for individual agencies from the Individual Management Reviews
• Recommendations to be implemented through the LSCB action plan.

8.37 The full overview report will contain names of family members and may identify directly or indirectly the staff who have been involved. An anonymised executive summary, which will be made public should also be produced. This will include as a minimum, information about the review process, key issues arising from the case and the recommendations.

LSCB Action Following Completion of the Overview Report

8.38 On receiving the 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;
• Decide whether the LSCB accepts the overview author’s recommendations or wishes to refine or add to them.
• 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. This plan should set out who will do what by when, with what intended outcome and how improvements in practice/systems will be monitored and reviewed;
• Decide to whom the report or any part of it, should be made available;
• Agree the timing of the publication of the executive summary taking into account the conclusion of any related court proceedings.  The LSCB should ensure that the SHA and OFSTED are briefed, so that can work jointly to ensure that the department of Health and the Department for Education and Skills respectively are fully briefed in advance of publication
• 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;
• Provide a copy of the overview report, integrated chronology, action plan and individual management reports to the relevant inspectorates

Reviewing institutional or complex abuse

8.39 When serious abuse takes place in an institution, or multiple abusers are involved, the procedures above will apply but the review is likely to be more complex, on a larger scale and may require more time. Terms of reference need to be carefully constructed to explore issues relevant to the specific case

8.40 Particular care needs to be taken to ensure clarity over the interface between;

• The different processes of investigation ( including criminal investigations)
• Case management (including help for the abused children and measures to ensure other children are safe)
• Review ( learning lessons from the case to reduce the chance of such events happening again)

Practice Guidance

• 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 (for example, school, nursery, family centre, YOI, STC, 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 promulgated, understood or acted upon?

Management Review Structure

What was our involvement with this child or family?

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.  Briefly summarise decisions reached, the services offered and/or provided to the child(ren) and family, and other action taken.

Analysis of Involvement

Consider the events which occurred, the decisions made, and the actions taken or not.  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.  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 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 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?
• 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 each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?

What Do We Learn From This Case?

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

What action should be taken by whom, and by when?  What outcomes should these actions bring about, and how will the organisation evaluate whether or not they have been achieved?

 LSCB Overview Report Structure

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 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.

LSCB Overview Report

Introduction

• Summarise the circumstances that led to a review being undertaken in this case.
• State the terms of reference of review
• List contributors to review and the nature of their contributions (for example, management review by LA, 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 summarise what relevant information was known to the agencies and professionals involved, about the parents/carers, any perpetrator, and the home circumstances of the children.

Analysis

This part of the overview 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 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.

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