See Chapter 8 of ‘Working Together to Safeguard Children’
When a child dies (including death by suicide), and abuse or neglect is known or suspected to be a factor in the death, the Safeguarding Children Board (SCB) should consider immediately whether there are any other children at risk of harm who require safeguarding (for example siblings or other children placed in an establishment where the abuse is alleged).
In such circumstances, the SCB should always conduct a Serious Case Review into the involvement with the child and family of agencies and professionals.
Additionally the SCB should also consider whether a Serious Case Review should be conducted where a child:
The purpose of reviews is to:
Serious Case Reviews are not enquiries into how a child died or who is culpable; that is a matter for Coroners and Criminal Courts respectively to determine, as appropriate.
Any agency or professional can refer a case to the SCB Chair or someone with delegated responsible if it is believed that there are important lessons for inter-agency working to be learned from the case.
The Secretary of State also has powers to demand an inquiry be held under the Inquiries Act 2005.
The SCB should consider the following questions when deciding whether a Serious Case Review is necessary:
In addition to the above there will be instances when a case does not strictly meet the criteria for a Serious Case Review but one agency decides to conduct its own internal review or a smaller case-audit. In these circumstances the findings should be made available to the Review Panel.
Any case brought to the attention of the LSCB Chair, or those with delegated responsibility, likely to meet the criteria for a Serious Case Review, will be discussed by the Review Panel (see Section 6, The Review Panel). The Review Panel will consider whether a Serious Case Review is necessary and their recommendation will be forwarded to the SCB Chair who has ultimate responsibility for deciding whether or not a Serious Case Review should be conducted.
The Chair will make arrangements to inform the Regulatory Authority of every case where a decision is made to conduct a Serious Case Review.
When more than one LSCB has knowledge of a child, the LSCB for the area in which the child is/was normally resident should take lead responsibility. Any other LSCB’s that have an interest or involvement in the case should be included as partners in jointly planning and undertaking the review.
In the case of Looked After Children, the responsible authority should exercise lead responsibility for conducting the review, again involving other LSCB’s with an interest or involvement.
Walsall SCB has a Serious Cases Review Panel as a standing subcommittee, made up of representatives from West Midlands Police, Health, Education and Children’s Social Care Services.
The Review Panel should consider in the light of each case, the scope of the review process and draw up clear terms of reference.
Relevant issues include:
Some of these issues may need to be re-visited as the review progresses and new information emerges.
Reviews will vary widely in their breadth and complexity, but in all cases, lessons should be learned and acted upon as quickly as possible. Within one month of a case coming to the attention of the SCB Chair, the decision should have been made on whether a Serious Case Review should take place. Individual organisations should secure case records promptly and begin work quickly to draw up a chronology of involvement with the child and family.
Reviews should be completed within a further four months, unless an alternative timescale is agreed with the Regulatory Authority at the outset. Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it emerges that a review cannot be completed within four months of the decision to initiate it, there should be a discussion with the Regulatory Authority to agree a timescale for completion.
In some cases, criminal proceedings may follow the death or serious injury of a child. Those co-ordinating the review should discuss with the relevant criminal justice agencies, at an early stage, 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 of relevant personnel), 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. Much useful work to understand and learn from the features of the case can often proceed without risk of contamination of witnesses in criminal proceedings.
In some cases it may not be possible to complete or to publish a review until after Coroners or criminal proceedings have been concluded but this should not prevent early lessons learned from being implemented.
Once it is known that a case meets the criteria for a Serious Case Review, each agency should secure records relating to the case to guard against loss or interference.
All agencies, through their designated ‘Contact Person’ will be informed about the Review and will be expected to undertake a separate management review of its involvement with the child and family. This should begin as soon as a decision is taken to proceed with a Serious Case Review, and even sooner if a case gives rise to concerns within the individual organisation. The contact person, in consultation with the Review Panel, will designate responsibility for the management review to a senior representative within that agency who has not been directly concerned with the child or family, and is not the immediate line manager of the practitioner(s) involved. The contact person will also be responsible for designating responsibility for ensuring that any recommendations from the review are acted on.
Relevant independent professionals (including GPs) should also contribute reports of their involvement.
Where a Children’s Guardian contributes to a review, the prior agreement of the Courts should be sought so that the Children's Guardian's duty of confidentiality under the Court rules can be waived to the degree necessary.
The aim of management reviews should be to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made, and if so, to identify how these changes will be brought about.
The purpose of a Management Review is to:
An outline format for the management review report is provided in paragraph 8.27 of Working Together to Safeguard Children, 2006.
The SCB should commission an Overview Report which brings together and analyses the information and findings of the various individual management reviews and any reports commissioned from others, draws conclusions and makes recommendations for future action.
The Overview Report should be commissioned from a person who is independent of all the agencies/professionals involved.
An outline format for Overview Reports is set out in paragraph 8.28 of Working Together to Safeguard Children, 2006.
On receiving an Overview Report, it is the responsibility of the LSCB:
It is the responsibility of the LSCB to consider how, when and in what form information should be shared with those who have an interest in the Serious Case Review, including elected members, staff, health trust members, the family, the media and the public.
The LSCB will need to bear in mind disclosure of third party information, the implications of any criminal or disciplinary processes and the impact of disclosure on any of the parties concerned.
It is important to anticipate requests for information and plan ahead how they should be met.
In all cases, the Overview Report should contain an Executive Summary which will be made public, and which includes at a minimum the review process, key issues arising and the reviews recommendations.
End