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Serious Case Reviews


CAPTION: contents list
1. Serious Case Review Process
  1.1 Criteria for Notifiable Incidents
  1.2 Criteria for Serious Case Reviews
  1.3 Decisions Whether to Initiate a Serious Case Review
  1.4 Referrals to the Case Review Group
  1.5 Methodology for Learning and Improvement
  1.6 Appointing Reviewers
  1.7 Timescale for Serious Case Review Completion
  1.8 Engagement of Organisations
  1.9 Agreeing Improvement Action
  1.10 Publication of Reports
  1.11 National Panel of Independent Experts on Serious Case Reviews
    Further Information
    Amendments to this Chapter

1. Serious Case Review Process

1.1 Criteria for Notifiable Incidents

A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected;
  • A looked after child has died (including cases where abuse or neglect is not known or suspected); or
  • A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

The local authority should report any incident that meets the above criteria to Ofsted, the Department for Education (DfE) and the relevant SCP or LSCPs promptly, and within five working days of becoming aware that the incident has occurred. In Cumbria the SCP Office completes a notification form, this is then signed by Children’s Services.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

1.2 Criteria for Serious Case Reviews

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCPs. This includes the requirement for LSCPs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an SCP’s function in relation to serious case reviews, namely:

  1. 5(1)(e) Undertaking reviews of serious cases and advising the authority and their partners on lessons to be learned;
  2. (2) For the purposes of paragraph (1) (e) a serious case is one where:
    1. Abuse or neglect of a child is known or suspected; and
    2. Either —
      1. The child has died; or
      2. The child has been seriously harmed and there is cause for concern as to the way in which the authority, their partners or other relevant persons have worked together to safeguard the child.

“Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCPs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter-agency working, the SCP must commission an SCR.

In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in Police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

(Working Together to Safeguard Children)

1.3 Decisions Whether to Initiate a Serious Case Review

The SCP for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 1.1, Criteria for Notifiable Incidents) for a Serious Case Review. In Cumbria this in delegated to the Case Review Subgroup of the SCP, who make a recommendation to the SCP Chair. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the SCP. The Chair may seek peer challenge from another SCP Chair when considering this decision (and also at other stages in the Serious Case Review process).

The SCP must notify Ofsted, DfE and the National Panel of Independent Experts within five working days of the Chair’s decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the SCP chair may be asked to give evidence in person to the panel.

The SCP Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The SCP will also want to review instances of good practice and consider how these can be shared and embedded. The SCP should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

LSCPs should consider conducting reviews on cases which do not meet the SCR criteria. If an SCR is not required because the criteria in regulation 5(2) are not met, the SCP may still decide to commission an SCR or they may choose to commission an alternative form of case review.

1.4 Referrals to the Case Review Group

The Child Death Overview Panel of the SCP may refer cases to the Case Review Subgroup as part of the Child Death Overview Process.

In addition, organisations may want to refer cases to the Case Review Group for consideration. See Referral for Case Review Group Form (found in the Documents Library section of this manual).

1.5 Methodology for Learning and Improvement

Working Together to Safeguard Children does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it should consider the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

The SCP Case Review Sub Group will consider the scope of the Review and draw up terms of reference which will be agreed by the Chair of the Safeguarding Partnership (SCP).

The Sub Group will need to consider and make decisions around the following:

  • Identify membership of the Expert Leads Panel who will oversee the SCR. Though this may include members of the Case Review Subgroup it may not always be appropriate;
  • Agree methodology for the SCR;
  • Discuss the period of time the review should concern itself with;
  • Consider what family history/background information do agencies already have and what needs to be captured to help gather a better understanding of the circumstances of the event(s)? This includes information gathering about parents/carers, siblings and significant figures outside of the immediate family such as partners of parents, etc.
  • Decide if there are any other professionals or individuals that can help contribute to the Review that has relevant information to inform the review?
  • Think about what appears to be the relevant issues involved in the case?
  • Decide how the Review should take accounts of a coroner’s Enquiry and/or any criminal investigations;
  • Consider who should be appointed as an Independent Lead Reviewer to conduct the SCR?
  • Consider whether the case gives rise to other parallel investigations?
  • Take account of media and public interest – how this should be handled before, during and after the Review. No individual agency member should speak to the press directly. Media and press interest should be managed through the SCP Chair who will agree and co-ordinate press statements;
  • If there is a need for legal advice to the Case Review Sub Group and if so who is to be approached to advise in this aspect of the work;
  • Whether family members should be asked to contribute to the Review process? If this is felt to be necessary and there are parallel criminal proceedings then the Police must agree on an appropriate course of action regarding interviews etc.

Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes when undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.

1.6 Appointing Reviewers

The SCP will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews.

The lead reviewer should be independent of the SCP and the organisations involved in the case.

The SCP will provide the National Panel of Independent Experts (see Section 1.10, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.

Working Together to Safeguard Children does not specify the need for an independent chair for the review process: the need for this will depend on the review model selected, the complexity of the case and other local considerations. The approach should be proportionate to the scale and level of complexity of the issues being examined.

1.7 Timescale for Serious Case Review Completion

The SCP will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

In addition, the SCP can require a person or body to comply with a request for information Section 14B of the Children Act 2004. This can only take place where the information is essential to carrying out SCP statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCPs should be mindful of the burden of requests and should explain why the information is needed.

1.8 Engagement of Organisations

The SCP will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

The SCP may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review known as a chronology. The form in which such written material is provided will depend on the methodology chosen for the review.

The SCP has developed a flowchart and briefing note that individuals, agencies and partners can use to help staff understand the process, and what their involvement in the SCR may be. This can be found in the Documents Library.

1.9 Agreeing Improvement Action

The SCP will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

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:

  • The review will be conducted in such a way that the process is a learning exercise in itself;
  • Consider what information needs to be disseminated, how, and to whom in light of a review. Be prepared to communicate both examples of good practice and areas where change is requires;
  • Focus recommendations on a small number of key areas;
  • The SCP should put in place a means of auditing action against recommendations and intended outcomes.

On receiving the SCR Report, at an SCP Meeting or Extraordinary meeting of the SCP, the SCP will:

  • Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report;
  • Translate recommendations into an action plan, which should be signed up to at a senior level by each of the organisations that need to be involved. The plan should set out by what means improvements in practice/systems will be monitored and reviewed;
  • Clarify to whom the report, or any part of it, should be made available;
  • Provide a copy of the overview report and action plan to Ofsted and DfE - 7 days before publication;
  • Disseminate report or key findings to interested parties as agreed. Make arrangements to preview feedback and de-briefing to staff, family members of the subject child, and the media, as appropriate.

1.10 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the SCP’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The SCP will comply with the General Data Protection Regulations (GDPR), Data Protection Act 2018 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

The SCP will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.
The SCP will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the SCP considers that a report should not be published, it should inform the panel which will provide advice. The SCP will provide all relevant information to the panel on request, to inform its deliberations.

1.11 National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children introduced a National Panel of Independent Experts to advise and support LSCPs about the initiation and publication of Serious Case Reviews. The panel reports to the relevant Government departments their views of how the system is working. LSCPs should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.

SCP Chairs and SCP members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

CAPTION: further information

Further Information

Referral for Case Review Group Form

NSPCC Serious Case Reviews Repository

Serious Case Review Quality Markers - Supporting dialogue about the principles of good practice and how to achieve them

Amendments to this Chapter

This chapter was updated in August 2019 to reflect the introduction of the General Data Protection Regulations (GDPR) and the updated Data Protection Act 2018.

This local content is currently under review. See also Child Safeguarding Practice Reviews, which sets out the national arrangements.