Serious Case Review

As soon as a serious case review is underway there are important lessons to be learned. These lessons could have direct implications for the way in which professionals work. This page will be dedicated to the effective dissemination of these lessons in order to help ensure such incidents do not happen again.

 

The purpose of Serious Case Reviews

The purpose of Serious Case Reviews is to:

  • Establish whether there are lessons to be learnt 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 on, and what is expected to change as a result
  • Improve inter-agency working and better safeguard and promote the welfare of children as a consequence

It is important to note that Serious Case Reviews are not a part of any disciplinary enquiry or process, but information that emerges in the course of reviews may indicate that disciplinary action should be taken under established procedures. Alternatively, reviews may be conducted concurrently with disciplinary action. In some cases (e.g. alleged institutional abuse) disciplinary action may be needed urgently to safeguard and promote the welfare of other children.

When should the MSCB undertake a Serious Case Review (SCR)?

The MSCB should always undertake a Serious Case Review when a child dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in the child’s death.

The Child Death and Serious Incident Overview Sub Group of the MSCB have knowledge of all child deaths and serious incidents in Manchester and can also make a recommendation for a SCR to take place based on the following criteria;

  • A child sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect; or
  • A child has been subjected to particularly serious sexual abuse; or
  • A parent has been murdered in a domestic violence situation and a homicide review is being initiated; or
  • a child has been killed by a parent or carer with a mental illness; or
  • the case gives rise to concerns about inter-agency working to protect children from harm.

In addition, any professional may refer such a case to the MSCB if it is believed that there are important lessons for inter-agency working to be learned from the case.

Agencies can initiate this by putting the referral in writing to the Chair of the Child Death And Serious Incident Overview Sub Group, outlining the reasons why they feel the requirements for a Serious Case Review have been met. The referral will then be dealt with in the same way as other referrals to the group.

The Secretary of State for the Department for Education and Skills also has powers to demand an inquiry be held under the Inquiries Act 2005.

Instigating a Serious Case Review

The Child Death and Serious Incident Overview Sub Group (CDSIOG) should first decide whether or not a case should be the subject of a Serious Case Review based on the criteria outlined in the previous section. The Sub Group’s decision should be forwarded as a recommendation to the MSCB Chair, who has ultimate responsibility for deciding whether or not to conduct a Serious Case Review.

The Chair must make a decision to accept or reject a recommendation within 4 weeks of receipt. If the recommendation is rejected, the MSCB Chair must inform the CDSIOG in writing of the reasons for this rejection. If the recommendation is accepted, representatives from the CDSIOG must meet as soon as possible to determine the scope of the SCR, identifying which agencies will be involved, how the family should be involved and the areas the Review should concentrate on, using the standard terms of reference for a SCR as a starting point

The MSCB Business Manager will inform the local region of the Commission for Social Care Inspection of every case that becomes the subject of a Serious Case Review and also identify an Independent Chair for the SCR as soon as the recommendation is accepted.

A letter should also be sent out from the Chair of the MSCB/CDSIOG to the parents of the child that has died to inform them that a Serious Case Review will be taking place. A leaflet should be devised as soon as possible to explain the process to the family.

Undertaking a Serious Case Review

Management Reviews

The initial scoping of the review will identify those who should contribute to the SCR, although it may emerge, as information becomes available, that the involvement of others would be useful. It is particularly important to speak to the family and carers of the child that has died if this is practicable.

Once it is known that a case is being considered for review, each organisation should secure records relating to the case to guard against loss or interference.

Each relevant service should 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 review, and even sooner if a case gives rise to concerns within the individual organisation.

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 those changes will be brought about. Those conducting management reviews of individual services should not have been directly concerned with the child or family, or the immediate line manager of the practitioner(s) involved.

The findings from the Management Review Reports should be accepted by the Senior Officer in the organisation who has commissioned the report and who will be accountable for ensuring that recommendations are acted on.

On completion of each management review report, there should be a process for feedback and debriefing for staff involved, in advance of completion of the overview report by the board. There may also be a need for a follow-up feedback session if the overview report raises new issues for the organisation and staff members.

Management reviews should be completed within one month of the service being notified of the SCR taking place. Guidelines and template for completing a Management Review can be found here.

Overview Report

The MSCB will commission an overview report and executive summary from an Independent Chair who is independent of all the agencies/professionals involved. This report brings together and analyses the findings of the various reports from organisations and others, and makes recommendations for future action.

Guidelines and a template for the Overview Report can be found here

Once produced by the Independent Chair, the Overview Report should be circulated to the agencies/individuals that contributed to the Serious Case Review to give them opportunity to ensure that their information is fully and fairly represented. The report should be physically signed off by an identified nominated Senior Manager within each organisation prior to its presentation at the MSCB.

NB Where there is disagreement about the Overview Report, the representative from contributing agencies will only have the right to challenge the Report where they feel it does not fully or fairly represent their single agency information. i.e. Where facts made available during the SCR are not included in the report, or information is inaccurate.

The style, content and findings of the report are the sole responsibility of the independently commissioned author and agencies have no right of challenge in these areas.

Where an agency wishes to challenge the Overview report, this should be made in writing to the Chair of the MSCB within 10 working days of receipt of the Overview report, outlining reasons. The Chair will then direct the author of the report to consider the representation and respond to the MSCB Chair within 10 working days. The Panel must be convened in this instance.

Once this has happened, the MSCB must receive the Report as a final document. This process should be completed within 4 months of the decision to undertake a SCR, unless an alternative timescale is agreed with OFSTED 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 Chair’s decision to initiate it, there should be a discussion to agree a timescale for completion.

Learning Lessons from Serious Case Reviews

This is the most important aspect of Serious Case Reviews in that the main aim of undertaking a review is to learn lessons to improve inter-agency working to safeguard children.

Following the completion of the Review, and approval of the Overview Report by contributing agencies, the following actions will take place within 4 weeks;

  • The MSCB Team will ensure recommendations are translated into an action plan that is signed up to by MSCB members of each of the organisations that need to be involved. The plan should set out who will do what, by when, and with what intended outcome. The plan should set out by what means improvements in practice/systems will be monitored and reviewed
  • The MSCB Team will provide a copy of the overview report, action plan and individual management reports to the CSCI and DCFS and ensure that an anonymised copy of the executive summary is placed on the MSCB website. This will include, as a minimum, information about the review process, key issues arising from the case and the recommendations that have been made.

It will be the responsibility of the MSCB Team to co-ordinate the implementation of the recommendations across all agencies, and co-ordinate audits that assess how well the recommendations have changed multi-agency working practices. This information will be supplied to the MSCB to support their function of ‘ensuring the effectiveness of multi-agency safeguarding work’

Accountability and disclosure

The following must be considered at the initial meeting of every SCR Panel:

  • Involvement of the family in the SCR. This should be included in the terms of reference for every SCR. If a decision is made not to involve the family, then reasons for this must be documented.
  • Information sharing with the family and other interested parties
  • A media strategy

These issues will be a standing agenda item at every meeting of the SCR Panel. Once the Review is complete, the SCR Panel will present recommendations for action regarding communication/disclosure for the MSCB to consider alongside receiving the final report. MSCB will carefully consider these recommendations and make decisions on disclosure. These decisions will be informed by legal advice.

These are often complex situations and there are many different and difficult interests to balance, including:

  • Protecting the integrity of the SCR process and maintaining a culture of frank and open debate
  • 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 may not be within the control of the MSCB.

The MSCB has also agreed following in relation to every Serious Case Review;

  • Management Review reports are the property of the agency that they relate to. Individual agencies will need to take their own legal advice in relation to disclosure requests relating to these reports. However, Management Review Reports must be disclosed to relevant Inspectorates (i.e. OFSTED) on request (paragraph 8.30, page 178 ,Working Together 2006)
  • That Overview Reports and Executive Summary and Action Plan are the property of the MSCB. The Executive Summary Report will be produced on the basis that it is a public document and will therefore always be anonymised.
  • For reasons outlined above, in particular, protecting the integrity of the process and ensuring contributions are full and frank so that lessons can be learnt, there will be a presumption of non disclosure for the Management and Overview reports.
  • The Overview and Executive Summary Reports must not be disclosed without the consent of the Board

Once decisions concerning disclosure have been made, it will be the responsibility of the MSCB Business Manager to ensure that relevant information is sent to appropriate parties as agreed. In addition, all additional requests for disclosure of documents must immediately be brought to the attention of the Business Manager.

Child death/serious incident involving a Manchester child that occur outside of the Manchester area

MSCB will take the lead on any review that relates to a child who is normally resident in Manchester, or is a Looked After Child placed by Manchester Council.

Any other LSCBs that have an interest or involvement in the case should be included as partners in jointly planning and undertaking the review.