• contents
• keywords & contacts
• quick guide
• values
• alerts & suggestions
• search

• the knowledge

Contents

Status

Purpose

Criteria for convening Serious Case Reviews 

Initiating a Serious Case Review

Membership of the Serious Case Review Panel

Disclosure of information in criminal proceedings

Family involvement

Immediate Action

Securing Records

Terms of Reference

Individual Management Reviews

Ongoing Action and Timescales

Overview Report and Follow Up

Executive Summary Format

Appendix 1: Format For Internal Agency Chronology
Appendix 2: Flowchart
Appendix 3:  Action Plan Structure 

Status

Chapter 8 of 'Working Together to Safeguard Children' defines the circumstances in which the Coventry Safeguarding Children Board (CSCB) should initiate a case review in Chapter 8 of that guidance, and describes in detail how it is to be conducted. Please also see

• Tim Loughton’s letter to Directors of Children’s Services and LSCB Chairs dated 10th June 2010 (which related to the publication of overview reports for serious case reviews initiated on or after 10 June 2010)
• Tim Loughton's letter to Directors of Children’s Services and LSCB Chairs dated 22nd September 2010 (which states that as from 1 October 2010, Working Together to Safeguard Children (2010) should be read as all references to Government Offices and GO Children and Learners Teams were omitted)

Under section 16 of the Children Act 2004 Local Safeguarding Children Boards ‘must take the guidance into account and, if they decide to depart from it, have clear reasons for doing so.

The following procedures summarise, with respect to serious case reviews:

• Their purpose and the criteria for conducting them;
• The process for their initiation and subsequent action;
• Actions consequently required of each member agency.

Purpose

Case Reviews are not enquiries into how a child dies or who is culpable; that is a matter for Coroners and Criminal Courts respectively to determine, as appropriate.

The purpose of serious case reviews is to:

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

Criteria for convening Serious Case Reviews

The same criteria apply to disabled children as to non-disabled children.

A case review must always be held when:

• A child dies (including suicide) and abuse or neglect is known or suspected to be a factor.

Additionally a Serious Case Review may be held when:

• A child has sustained a potentially life threatening injury or serious and permanent impairment of physical and/or mental health or development through Abuse or Neglect;
• A child has been seriously harmed as a result of being subjected to Sexual Abuse;
• Their parent has been murdered (including domestic violence situations) and a domestic homicide review is being initiated;
• The child 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.

In cases where a child has not died it may be appropriate to hold a serious case review if one or more of the following criteria are met:

• There was a significant risk of harm to a child which was unrecognised by agencies or professionals in contact with the child or alleged perpetrator, or not shared with others or not acted upon properly;
• The child was abused in an institutional setting, e.g. school or family centre;
• The child dies in a custodial setting;
• The child dies whilst absent having run away from home;
• The child was being Looked After by the local authority at the time of abuse;
• Agencies or professionals consider that their concerns were not taken sufficiently seriously or acted upon appropriately by another;
• The case indicates that there may be failings in one or more aspect of the local operation of formal child protection procedures which extend beyond the handling of the case;
• The child was, or had been, subject to a Child Protection Plan or deemed to be at the threshold of risk of Significant Harm;
• The case appears to have implications for a range of agencies or professionals;
• The case suggests that there may be a need for the Coventry Safeguarding Children Board (CSCB) to change its protocols or procedures or that they need to be more effectively promoted, understood or acted upon.

Where Coventry Safeguarding Children Board (CSCB) is taking the lead, any other Local Safeguarding Children Board (LSCB) with an interest or involvement in the case will be notified of the decision to hold a review and included in the planning and undertaking of the Review.

Where another Local Safeguarding Children Board is conducting a review which involves a child or family from the City, the Safeguarding Children Board will cooperate with these reviews.

Initiating a Serious Case Review

The decision to undertake a Serious Case Review ultimately rests with the Chair of the Safeguarding Children Board acting on the recommendation of the Serious Case Review Sub-Committee.

The Serious Case Review Sub-Committee will consider the circumstances of any child death where member agencies consider the criteria for a Serious Case Review may be met.

The role of the Serious Case Review Sub-Committee is to coordinate and manage the Review process on behalf of the Safeguarding Children Board.  The sub-Committee has responsibility for deciding if the criteria for a Serious Case Review have been met and to consider the scope of the review and draw up terms of reference.

Members of the Sub-Committee may determine that a full case review is not justified and that internal management reviews might be more helpful. The results of any internal reviews within member agencies should be fed back to the Serious Case Review Sub-Committee. The status and importance of these reviews is the same as a Serious Case Review. 

If the sub-Committee concludes that a review is required, it should make this recommendation to the Chair of the Coventry Safeguarding Children Board (CSCB) who has the final responsibility for making the decision.

The Serious Case Review Sub-Committee will consider the scope of the review and draw up terms of reference. Relevant issues may include:

• What appear to be the most important issues to address in identifying the learning from this specific case? How can the relevant information best be obtained and analysed, including, for instance, information on the mental health of relevant adults?
• When should the SCR start, and by what date should it be completed, bearing in mind the timescales for completion set out below? Are there any relevant court cases or investigations pending which could influence progress or the timing of the publication of the 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 SCR, and who should be responsible for facilitating their involvement? How will they be involved and contribute throughout the overall process?
• Are there any specific considerations around ethnicity, religion, diversity or equalities issues that may require special consideration?
• 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 SCR including, where appropriate, for example the proprietor of an independent school or a playgroup leader?
• Who will make the link with relevant interests outside the main statutory organisations, for example independent professionals, independent schools, independent healthcare providers or voluntary organisations?
• Is there a need to involve organisations/professionals working in other LSCB areas (see paragraph 8.13), 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 SCR?
• 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 SCR sub-committee or the SCR Panel - see paragraph 8.33);
• Might it help the SCR Panel to bring in an outside expert at any stage, to help understand crucial aspects of the case?
• Will the case give rise to other parallel investigations of practice, for example, into the health or adult social care provided or 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) 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 (SUI) investigation into the provision of healthcare should be co- ordinated with a SCR;
• How will the SCR terms of reference and processes fit in with those for other types of reviews - for example, for homicide, mental health or prisons?
• How should the review process take account of a coroner's inquiry, any criminal investigations (if relevant), family or other civil court proceedings related to the case? How will it be best to liaise with the coroner150 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 SCRs) and from SCRs which have been undertaken by the LSCB?
• How should any family, public and media interest be managed before, during and after the SCR? In particular, how should surviving children (where appropriate given their age and understanding) and family members be informed of the findings of the SCR?

A Serious Case Review Panel will be arranged by the Sub-Committee. A Chair, the author of the overview report, members and co-opted members will be identified.

Membership of the Serious Case Review Panel

Membership of the Panel will usually be drawn from the constituent agencies at levels of sufficient seniority and may include others with relevant professional or specialist knowledge.

The Panel will not include anyone who has had direct contact with the family, or any direct management responsibility for the case. All members of the Serious Case Review Panel must possess a sound understanding of child protection issues.

Panel members may be the authors of the agency management reviews. However wherever possible, Panel members should be independent from the production of the management review.

Membership of a Panel would usually include:

• Children’s Social Care Services;
• Designated doctor and designated nurse from the PCT and Hospitals;
• Police representation;
• Education Department representation;
• Designated Manager for Children Subject to a Child Protection Plan;
• Legal Adviser - where appropriate;
• Specialist Consultant – where appropriate;
• Administrative support.

Black and minority ethnic children

Whenever the child involved is black or from a minority ethnic community, it may be appropriate to involve a consultant to ensure that any significant issues of race, racism or racial harassment are properly addressed. All aspects of the case should be considered, including whether assessments made and services provided were sensitive to the child and family’s race, culture, language and religion, and did not disadvantage them.

In addition, a decision should be made about who will link with relevant interests outside the main statutory agencies.

Any lessons learned in how to work better with particular communities, or how to work better in partnership with other agencies, should be highlighted.

Children with a disability

Whenever the child involved has a disability it may be appropriate to involve a consultant to ensure that any significant issues relating to disability are properly addressed. In particular, a judgement should be made about whether assessments made and services provided were appropriate to the individual child and their family and did not disadvantage them. 

Any lessons learned about how to work better with children with disabilities and their families, or how to better protect children with a disability should be highlighted.

Disclosure of information in criminal proceedings

The Chair of the Serious Case Review Sub-Committee will liaise with the Police Detective Chief Inspector (DCI) with responsibility for child protection to ascertain whether the timing of any criminal proceedings need to be taken into account for the production of management reviews and the subsequent publication of the overview report. The DCI should consult with other parties about the criminal proceedings such as Coroner, Crown Prosecution Service etc as to their views on timing and disclosure of information. 

Once an agreement has been made between the Chair of the Serious Case Review Sub-Committee and Detective Chief Inspector regarding timing and disclosure, this should be reviewed regularly at strategic points in the criminal proceedings and serious case review process e.g. prior to, and following the trial. Authors of management reviews should be made aware that their reviews may be disclosed as evidence, or used in subsequent proceedings. 

Family involvement

The family must be informed by the Serious Case Review Sub-Committee that a Serious Case Review is being conducted, together with an explanation of the general purpose of such Reviews (as per paragraph 8.20 of Working Together to Safeguard Children, 2010) at the earliest opportunity.  The Review Panel will take responsibility for ensuring this happens in a timely and sensitive way, and identify the most appropriate person for this task.

A decision should be made at the scoping stage and then regularly reviewed by the Panel as to how and the extent of involvement of the family in the review process. The family will usually be asked if they wish to contribute to the review, and various ways of doing this will be discussed with them.

The family should be informed that Working Together requires that the findings of the review are made public. This will be through the publication of an executive summary and the overview report. The family should be reassured that the reports will be anonymised and their identity and privacy protected.

The "family" refers primarily to persons with Parental Responsibility, but those with a legitimate interest in the child may also be involved if the Coventry Safeguarding Children Board (CSCB) believes this to be in the best interests of the child and purposes of the review, and taking into account the views of those with Parental Responsibility.

Immediate Action

As soon as the Chair of Coventry Safeguarding Children Board has agreed that a serious case review is required, s/he must immediately inform the Designated Manager for Children Subject to a Child Protection Plan who must then complete the following tasks:

• Confirm that arrangements have been made (where necessary via a Strategy Meeting) to ensure the safety of other children or family members.  Additionally consideration is given to the support needs of adult carers in the family;
• Check the Social Care client index and other relevant records to establish if the child or any other member of the family was previously known.

The Chair of the Serious Case Review Sub-Committee will provide written notice to all agencies of the intention to hold a Serious Case Review and inform the Regulatory Authority at the Department for Education on behalf of the Safeguarding Children Board.

The early warning to relevant agencies should cover the need for designated professionals to:

• Liaise with the case accountable social worker before making contact with the family;
• Secure all records relating to the child and their family;
• Ensure adequate support for those staff involved.

Within two further working days, the Chair of the Serious Case Review Sub-Committee should ensure that a briefing report for the Director of Children, Learning and Young People Directorate (in his/her statutory role as the Director of Children’s Services) and the Chair of Coventry Safeguarding Children Board is prepared.

Securing Records

When a request is made to secure the records a senior manager in each agency must take possession of the file and a print out of the computer records should be run off to maintain a record of the case. Within all agencies, a photocopy of the file must be made so as to allow ongoing work.  The manager conducting the agency review will hold the original file.

Files should not be entrusted to the postal service and must be delivered in person or couriered.

Terms of Reference

The Serious Case Review Panel will work to the terms of reference agreed by the Serious Case Review Sub-Committee at the scoping stage.  The terms of reference may be amended or revised in the light of additional information.

The Panel should consider the need to liaise with the City Councils press officer for advice in dealing with matters of public interest and situations where the family seek to involve the press.

The Panel should take legal advice on the implications of the Freedom of Information Act 2000 if necessary.

Individual Management Reviews

The main objectives of each agency’s management review are to:

• Look openly and critically at organisational and individual practice;
• To establish if the case indicates that changes could and should be made;
• Identify how any such changes may be introduced;
• Propose any other action required.

To achieve these objectives, the following will need to be completed:

• A chronology of agency involvement;
• Identification and reading of file material;
• Interviews with relevant practitioners and managers;
• A determination of which services were provided as a result of decisions made;
• An analysis of involvement;
• A summary of ‘lessons learned”;
• Recommendations for the agency.

Further details on the conduct of Individual Management Reviews are provided in Working Together to Safeguard Children, 2010, starting at 8.234.

Whilst the specific processes may differ given the variety of organisational arrangements that exist, each agency’s approach should satisfy the following general points:

• The review should be conducted by a person of sufficient seniority with relevant knowledge and experience who has had no line management involvement in the case and can retain objectivity;
• Case reviews are not disciplinary proceedings and should be conducted in a manner which facilitates learning;
• Appropriate arrangements should be made for support of those staff involved;
• Information that emerges during a case review may indicate that disciplinary action should be taken under established procedures.  A decision of this sort should not usually delay the completion of a Serious Case Review;
• Those conducting the review should have access to all relevant case records;
• All relevant staff should be interviewed and given an opportunity to comment upon the accuracy of their contribution before it is shared outside the agency. Staff are entitled to be supported by an individual/organisation of their choice;
• Once the need for a case review is agreed, no member agency should comment publicly upon the case without the express agreement of their senior management and the chair of the Coventry Safeguarding Children Board (CSCB).

Reports such as a Health Trust ‘serious incident report’ may be combined with the internal agency review so long as they still satisfy the criteria above

Format and Approach

A common format for chronologies should be used; the format in Appendix 1 has been agreed for use by each agency. Particular cases may justify modification, e.g. the addition of time of contact.  A separate chronology should be produced for each child in a family and will be subsequently combined at the production of the overview report. 

Staff should be referred to as social worker (SW) 1, 2 etc; health visitor (HV) 1, 2 etc and identities not divulged beyond the Serious Case Review Sub-Committee. It may be helpful to include quotations from records of contacts. The origin of material – i.e. written records or interviews should be made clear.

It is vital that commentary on an agency’s practice is open, analytic and reflects trust in the integrity and usefulness of the process.

Ongoing Action and Timescales

The Serious Case Review Sub-Committee will oversee the conduct of the review.  The Panel will usually meet regularly as management reviews become available to consider in detail the contents and seek further clarification if necessary.

The overall time limit for submission of a serious case review report to Ofsted is six months from the decision that such a review is required. However, if the complexity of a case or other circumstance warrants additional time, an alternative should be negotiated with Ofsted.

A draft copy of the final report will be shared with contributing agencies to check for accuracy.

The overview report should be completed and submitted to the Serious Case Review Sub-Committee within one month of all the internal reviews being received.

Overview Report and Follow Up

The Chair of the Serious Case Review Panel responsible for the production of the overview report, together with its independent author, will present the report to the full Coventry Safeguarding Children Board (CSCB).

The Report will:

• Provide an overview and include all relevant facts;
• Provide an integrated chronology, using the template for internal agency chronologies;
• Make recommendations for action by the Coventry Safeguarding Children Board and individual agencies.

The format of the overview report should follow the format recommended by Working Together to Safeguard Children, and include:

• An introduction summarising the circumstances which led to the review, includes its terms of reference and listing all contributions and contributors (including family members) as well as clarifying the case review panel members and the author of the report;
• Facts including a genogram, and integrated chronology showing involvement of all agencies and an overview of what relevant information was known to each involved agency and professional, about the parent/carer, any perpetrator, and the home circumstances of the child/ren;
• An analysis which considers how and why events occurred, decisions were made and actions taken or not. This section can consider if outcomes might have differed if different decisions or actions had been taken and can also usefully include examples of good practice.  Unless legal reasons prevent it, the involvement of members of the family of the child who died may be useful to ensure that they are:
• Given and contribute as much information as possible;
• Given an opportunity to share their views about the services they were receiving;
• Conclusions and recommendations in which the lessons to be drawn are outlined and proposals included as to their progression by relevant agencies (such conclusions and recommendations should be SMART i.e. Specific, Measurable, Realistic, Achievable and Timely).

Accountability And Disclosure

See letter from Tim Loughton to Directors of Children’s Services and LSCB Chairs dated 10 June 2010, which changes the guidance in Working Together 201 and requires the publication of overview reports for Serious Case Reviews initiated on or after 1 June 2010.

The Coventry Safeguarding Children Board should consider carefully who might have an interest in reviews and what information should be made available to each of these interests. There are difficult interests to balance and consideration must be given to:

• The need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others;
• The accountability of public services and the importance of maintaining public confidence in the process of internal review;
• The need to secure full and open participation from the different agencies and professionals involved;
• The responsibility to provide relevant information to those with a legitimate interest;
• Constraints on public information sharing when criminal proceedings are outstanding, in that providing access to information outside the control of the Coventry Safeguarding Children Board.

The Coventry Safeguarding Children Board (CSCB) must either endorse the report and its recommendations or agree some alternative/s.

The Chair of the Coventry Safeguarding Children Board will agree a process to disseminate the findings and recommendations of the case review so as to ensure that all opportunities for service improvements are acted upon.

When an agreed action plan is formulated, the chair must ensure that the Coventry Safeguarding Children Board has in place effective mechanisms to monitor progress and within six months receive a report upon the implementation of agreed action points.  Action plans should follow the structure given in Appendix 3.

The overview report will be made available to the constituent agencies of Coventry Safeguarding Children Board and to senior managers and managing authorities of individual agencies participating in the review.

The CSCB will ensure that the Department for Education and Ofsted are briefed and reports are shared with the respective agencies in advance of the publication of the executive summary and overview report.

The PCT will inform the Strategic Health Authority and seek feedback on the recommendations of the Serious Case Reviews.

The Serious Case Review Sub-Committee will take responsibility for giving feedback to the family. This should be provided with some explanation and support.

Each agency must ensure that a process is in place which enables feedback and debriefing of staff involved. Seminars or workshops for staff and teams directly affected will be organised by the Serious Case Review Sub-Committee, wherever possible this will be delivered in a multi-agency forum.

Executive Summary Format

Working Together to Safeguard Children 2010 paragraph 8.42 makes it clear that in all cases the overview report should contain a suitably anonymised executive summary that will be made public and which includes at minimum information about the review process, key issues arising from the case and the recommendations.  The Executive summary should follow the recommended format.

The publication of the executive summary will need to be timed in accordance of any related court proceedings

Appendix 1: Format for Internal Agency Chronology

Please click here to view the Format for Internal Agency Chronology.

Appendix 2: Flowchart

Please click here to view this flowchart.

Appendix 3: Action Plan Structure

Please click here to view the Action Plan Structure.

End