The following is designed as guidance to follow when completing a serious case review. It is not South West policy. This will be redrafted in light of the forthcoming Working Together.
Introduction
This paper is designed to describe the requirements in Chapter 8 of Working Together to Safeguard Children and to offer some suggestions for practice. It is designed to assist in producing a LSCB procedure for serious case reviews. Reconstruct’s suggestions are prefaced by ”could”.
This version has been produced after publication of the latest edition of Working Together to Safeguard Children and after sight of Ofsted’s proposed framework for the evaluation of serious case reviews.
It is drawing upon Social Care Institute for Excellence (SCIE) Learning together to safeguard children: A systems model for case reviews (2009), material from the NSDU sponsored pilot training for independent chairs and overview report writers and Reconstruct’s experience of conducting serious case reviews.
Purpose
‘The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children.’ (Working Together 8.1).
‘To be effective a serious case review must include consideration of the lessons that can be learned within each of the services involved in a case, as well as how they co-operate together’, Laming (2009). The purpose is therefore not to produce a fine overview report but to improve outcomes for children. This view has been further endorsed by the focus in Working Together on action plans and Ofsted’s focus on depth of learning, recommendations and action plans, review process and overall effectiveness.
Additionally the review should be respectful and considerate of the child and family and be conducted in such a way that includes family members.
Criteria
There are two sets of criteria identified in ‘Working Together’ (Para 8.9) that relate to the need to undertake a serious case review. The first is mandatory and relates to circumstances:
‘When a child dies, (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death’.
The second category is discretionary. ‘Working Together’ states that ‘LSCBs should always consider whether a serious case review should be conducted where’:
(a) A child sustains a potentially life threatening injury, or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; or
A child has been seriously harmed as a result of being subjected to sexual abuse; or
A parent has been murdered and a domestic homicide review is being initiated; or
A child has been seriously harmed following a violent assault perpetrated by another child or an adult;
and
(b) 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.
Decision
The local safeguarding children board usually have a standing SCR sub-committee, whose purpose is to oversee and recommend the instigation of SCRs, disseminate learning, ensure integration of recommendations into LSCB business plans and, now, quality assure the whole SCR process. This group is not the panel that will meet to oversee an individual SCR though people could be members of both providing that they are independent of the case being discussed.
The decision to recommend a serious case review lies with the chair of the local safeguarding children board. Any professional can make a referral to this person requesting a review. This could be done in writing setting out the reasons for the review.
The Secretary of State can also demand a review.
Purpose of serious case reviews
Experience and guidance is now clearly pointing to the fact that the purpose of a serious case review is to learn lessons and better protect children. Therefore Ofsted will now be measuring;
• the depth of learning,
• the quality of recommendations and the action plan,
• the quality of the review process,
and will no longer be commenting upon the constituent parts of each SCR.
As part of the quality control process there is now an expectation that the LSCB will be responsible for assessing all IMRs, the overview report, the process itself, recommendations and action plans.
Initiating the process
The SCR sub-committee could meet within two weeks of the decision being made to set up a SCR panel. In some LSCBs the sub-committee and the panel may be the same, this is acceptable.
When identifying panel members, consideration should be given to ensuring that they provide the right skills and carry sufficient authority.
Whilst it is hoped that this has been done already the safeguarding manager could consider how the family will be approached. Family could be defined broadly and could include grand-parents, uncles, aunts etc. Consideration could be given to involving friends of older children. In cases where a criminal inquiry has taken place this could be co-ordinated by the police. This guide contains advice about approaching family members after a tragedy has occurred, (appendix one).
Once a decision has been made to instigate a serious case review the LSCB Chair should notify Ofsted who will then pass this information to the relevant Government Office and the Department for Children, Schools and Families. The SCR sub-committee should draw up initial terms of reference, identify members who can sit on the SCR panel and appoint an independent chair and overview author, these cannot be the same person.
A letter from the Board chair could be sent to the chief executive of each relevant agency (and copied to their respective Board representative), advising them that records relating to the child and family should be secured, and requesting that the process be set underway to undertake their individual management reviews.
If there are draft terms of reference, these should be included in the letter and IMR authors could be informed that the analysis sections of their reports should explicitly address any key issues relating to the case.
Working Together states that someone on behalf of the health commissioners (the PCT) should produce an integrated Health chronology and IMR. This has been the practice in some LSCBs and makes sense, however it does mean that Health will need to be given more time to produce their draft IMR.
The IMR should be ‘quality assured by the senior officer in the organisation which has commissioned the report’, WTSC 8.35.
Role of independent chair
The chair has the responsibility for managing the process and guiding the Panel in quality assuring the reports. They could ensure that there has been appropriate contact with the family throughout the SCR process following the death or injury, that staff are appropriately supported during the process and that the family are met with. This does not mean that they necessarily have to do any of these things themselves.
Although the independent chair of the LSCB may chair the panel the SCR sub-committee should consider whether there may be any conflict in the LSCB chair commissioning, and ultimately having to approve, a report from a panel that they chair.
Planning
The six month timescale starts at the point that the chair of the Board decides that a review is to take place. Therefore time is now of the essence and a minimum of four SCR panel meetings could be arranged to consider the progress of the review. These could be set in advance. Although the overview report author is not a ‘member’ of the panel they should, if possible, attend each meeting in order to be able to contribute to the discussions and understanding and to reflect the panel’s views within the report.
The relevant Government office should be approached immediately if it looks like the timescale is likely to slip.
The first SCR panel meeting should discuss the case, agree the terms of reference (a draft may have been produced already) and identify the agencies who will be involved in producing individual management reviews. It should also consider whether it will require any expert advice.
Briefing sessions for IMR authors could be established immediately. These could be led by the SCR panel chair, an independent person, overview author or the LSCB safeguarding officer. The purpose is to outline the requirements of an IMR and answer initial queries.
Individual management review authors could be identified and told that their chronology should be available within two weeks and their first draft report should be available in four weeks, one week before the second Panel meeting. This will allow SCR panel members time to read the individual management reviews prior to the meeting. The chronologies could be put together into a joint chronology as soon as they are available. Individual management reviews should follow the same format, to be described later in this paper and authors must complete the same template for chronologies to enable a joint chronology to be compiled.
If a draft IMR is not complete by the first Panel meeting then the chronology and a progress report should be sent to panel members. Review authors could attend individually, to be questioned about their reports and engage in discussion about the story and the different viewpoints that are emerging. At later panel meetings it may be appropriate to have a number of IMR authors together so that they can discuss the case and interactions between agencies with each other as well as the Panel.
The reports will need to be quality assured and if there are areas for improvement the author will need to make changes in line with the comments from the panel.
The second SCR panel meeting could identify whether any staff need to be interviewed (or re-interviewed) and decide upon who should conduct the interviews. It should also list the ”r;why” questions that the IMR authors have developed during the process of the production of their draft report. These will form the initial hypotheses that the overview author will address. The overview author could be able to see staff as that author will have a more systemic view of the case than the IMR authors and could have already seen the family. Conversations with staff could be conducted in pairs and the IMR and overview author are likely to be a good combination to allow for notes to be taken. These notes could then be passed to the interviewees, along with any thoughts that the interviewers may have, to allow the interviewee to comment further.
The involvement of children and family members is a crucial but often neglected area for serious case reviews. The first SCR panel meeting could identify which family members should be involved, though this may already have been done. This decision could be made without reference to culpability, guilt or the emotive feelings that such cases engender. The person who actually killed or injured the child may have very useful information that can be made available to the panel. The purpose of involving family members and friends early on in the process is that they often offer lines of inquiry which may not be present in IMRs. For this reason we recommend that the overview author, who is the person most likely to be involved with the family, could interview key members of staff as they are then in a good position to assess the views of staff and family.
It is often the case that family have been interviewed by police officers who are conducting a criminal investigation. This needs to be considered and it may be helpful if a protocol is designed between the LSCB and police to identify which information will be shared between the two processes and when this will be appropriate.
The overview author could conduct the meetings with the family members. It is useful, if appropriate, for two people to be present. Notes should be taken and these notes should then be passed to the interviewees, along with any thoughts that the interviewers may have, to allow the interviewee to comment further.
It is crucial that recommendations are implemented as the process unfolds, there is no need to wait until the review has been completed.
Timescale
It can be difficult to meet the six month timescale particularly if there are separate reviews or criminal proceedings. Known delays should be immediately notified to Government Office. Simple recommendations can be implemented and lessons learnt disseminated immediately, there is no need to wait until the end of the review.
A rough guide to timescale could be:
Week 1-5: initiate process, inform Ofsted and Government Office, complete individual management reviews, produce joint chronology.
Weeks 5-9: consider and refine individual management reviews. Begin to draft the overview report.
Weeks 5-14: analyse individual management reviews, interview family and staff, complete the narrative part of the overview report. Implement simple single agency recommendations.
Weeks 15-18: define recommendations from overview report, complete overview report, carry out dissemination of learning.
Weeks 19-20: Quality assure whole process at SCR sub-committee meetings.
Weeks 20-23: Formulate final action plan.
Weeks 23-26: Discuss report and executive summary at full LSCB meeting.
Where an extension beyond the six months is required an update on progress and a revised project plan should be produced quickly for the relevant Government Office to consider. This update should include recommendations for action where these are not dependant on the SCR being concluded.
Terms of reference
Compiling good terms of reference is crucial to the running of a review. A draft should be produced at the beginning of this process but the SCR panel should be prepared to review and modify these in light of events.
Working Together lists the following for terms of reference.
• What appear to be the key issues to address in identifying the learning from this specific case? How can the relevant information best be obtained and analysed?
The individual management reports and overview report should directly address the key issues contained in the terms of reference, in fact these could be separate headings and be contained explicitly in the analysis of the IMRs and overview reports.
• When should the SCR start, and by what date should it be completed? 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? It could be appropriate to set the end date after the event that led to the review to consider the protection of siblings or other children.
• 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 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).
• 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 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 coroner 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?
Some of these issues may need to be revisited by the SCR Panel as the review progresses and new information emerges. This reconsideration of the issues may in turn mean that the terms of reference will need to be revised and agreed by the LSCB Chair.
A further consideration for terms of reference is the relationship between the independent author and the LSCB. Specifically what will happen if the Panel and the overview author disagree? We recommend that the report belongs to the author not the LSCB, so, in the event that there is disagreement the LSCB should produce an addendum and comment upon these differences. The action plan is entirely the prerogative of the LSCB.
The terms of reference should be sent to the relevant Government Office who will comment.
It is not necessary to replicate the terms of reference in each individual management review.
Individual Management Reviews
Each agency whose workers had some contact with the family will need to produce an individual management review. Once the request is made the agency should:
1. Appoint a senior manager (or an independent person) to undertake the task of completing the review and compiling the relevant report for the SCR panel. This manager should not have been directly concerned with the child or family, or the immediate line manager of the practitioners involved.
2. Ensure that all relevant files are secured and made available to the writer.
3. Ensure that the report writer is allocated adequate resources (time, admin support) to complete their report within the required timescales. It is imperative that timescales are adhered to in order that the role and actions of the agencies involved with the family can collectively be reviewed by the Panel. Most IMRs require at least two full days of work, and some take much longer.
4. Ensure that any staff involved with the child or family have been given the opportunity to discuss their understanding of what has happened. It is essential that support and counselling be offered. Support should be ongoing and reviewed regularly by the line manger.
The IMR is based around a chronology. The chronology should be in date order and could use the following headings:
Date When did it happen?
Event What happened?
Responsible Agency Which agency was involved?
Worker Which worker was involved?
Source or record Where did the information come from?
Child seen When was the child seen and were they seen alone?
Contact with the perpetrator (if relevant) should be clearly marked.
Author’s comments What is the author’s assessment of the significance of this event or appropriateness of the action taken?
Unlike ICS chronologies the IMR chronology could contain every case record. Ideally case records are cut and pasted into the IMR chronology.
Individual management reviews are documents in their own right and could be produced upon the agency’s headed paper. The main purposes of these agency reviews are:
• to highlight the contact that the agency had with family members,
• reflect upon that contact,
• identify lessons to be learned by the agency and in terms of multi-agency working,
• make recommendations for the individual agency and for the safeguarding children board as a whole.
Individual management reviews should be signed and dated by the author and counter-signed and dated by an appropriate senior manager of the agency.
Ofsted have criticised many reports for failing to give due attention to ethnicity, disability, research and the voice of the child and these are themes that should be addressed by authors of individual management reviews and overview reports. Questions that could be answered by all authors is ‘How did the agency respond to the racial, cultural, linguistic identity of the child and family?’ ‘How did the abilities of the child and family members impact on the situation?’
It is not enough to state the ethnic background of the child and their family. Thought needs to be given to how these factors impacted on the child and the work. Consideration should be made with regard to how well the workers dealt with, and recorded, these issues as well as the author commenting upon their view of how the factors influenced the case.
If possible try to see the situation through the eyes of the child. The voice of the child is often missing from case records and reports. Where this is the case authors should always comment upon it and, where possible, ensure that the child’s viewpoint is present and considered in their reviews.
Individual management reviews should adopt the following headings:-
Introduction
Outline a summary of the case, add a family tree, (if you have information) and suggest areas that need exploring.
Methodology
Simply explain the process that has been followed to obtain the information. For example, which reports were read, who was interviewed, over what time period, by whom, etc.
Chronology
This must follow the standard headings adopted by all individual agency review authors and be written as a table. It should specifically record each time the child was seen, if the child was seen alone and whether the child’s wishes and feelings were sought or expressed. It should be included in the report as an appendix.
Narrative
This is the story that emerges from the chronology. Suitable headings could be 2002, 2003 etc. The purpose of this section is to bring the chronology to life. There need be no comment from the author regarding practice during this section.
It is important that all facts are attributed. For example it is not enough to say ‘Mrs. S. was upset’, rather it should be ‘According to the social work case record Mrs. S. told SW1 on 17/07/08 that she was upset’.
The narrative should comment upon how often the child was seen and whether they were listened to.
Where an agency has had relevant contact with the alleged perpetrator, the chronology should also cover these actions and should ask whether everything was done which might reasonably have been expected to manage effectively the risk of harm posed by the alleged perpetrator to the child.
Analysis
This is the most difficult part of the report. Analysis is the author’s reflection on the narrative and comments upon the actions taken or not taken. The analysis should explicitly address the key points identified in the terms of reference and use them as headings in the analysis. It should also identify themes that have emerged from the narrative and comment upon them.
The author should also be identifying further ”r;why” questions. It may not be possible during the production of the first draft IMR to find out answers to these questions but they could form questions that the overview author will address. ”r;Why” questions can rarely be answered without interviewing the child, staff or family members. For example a report may identify that procedures were not followed but a good recommendation cannot follow unless the question, ”r;why were the procedures not followed?” is addressed.
The new Working Together suggests that the following should be included and I would recommend that this is covered in the analysis.
• Communication between professionals and agencies
• Child protection plans
• Consideration of resources (or lack of them)
• Accountability of senior managers
What do we learn from this case?
These could be listed as bullet points as they will form the basis of the recommendations. It may be helpful to group them in terms of
• National lessons
• Agency specific lessons
• LSCB lessons
Furthermore SCIE suggest taking an approach that looks at the underlying patterns of systemic factors. Their categorisation is:
1. Human-tool operation, how staff manage the computer systems and paperwork that they are required to use,
2. Human-management system operation, how staff respond to the management culture and supervision, resources,
3. Communication and collaboration in multi-agency working in response to incidents/crises (self explanatory)
4. Communication and collaboration in multi-agency working in assessment and longer term work (self explanatory)
5. Family-professional interactions, the relationships that workers make with family members
6. Human judgment/reasoning, staff’s ability to analyse, plan and reflect on those actions.
Good practice should also be included.
IMRs should be fully anonymised (except for names of author and senior officer) by the time they are sent to Ofsted. However it can be helpful during the SCR process if names are used as this makes it easier for the panel to remember who is who.
Recommendations
These need to be short, punchy and unambiguous.
SCIE (page 24) suggest that there are three different kinds of recommendations:
1. Issues with clear cut solutions that can be addressed locally and by all relevant agencies
2. Issues where solutions cannot be so precise because competing priorities and inevitable resource constraints mean there are no easy answers.
3. Issues that require further research and development in order to find solutions, including those that would need to be addressed at a national level.
Authors could be careful about recommending ”r;review” and ”r;training” as these are easy to state but time consuming to apply. When people fail to do something that they probably know they should be doing, more training is unlike to improve matters.
The child and family’s real situation should be described. Whilst few professionals would describe someone as an ‘alcoholic’ they are happy to write ‘had a problem with alcohol’. Neither tell the reader anything useful at all about the situation. ‘She told social worker (1) on 18/08/09 that she regularly drank 6 cans of strong lager every morning and consequently spent every afternoon asleep’ is the sort of detail that is required. Similar points can be made about ‘domestic violence’, ‘drug use’, ‘substance misuse’, etc.
Action plans
So far Ofsted have approved of SMART: (specific, measurable, actioned, realistic and timescaled) action plans. However some issues do not lend themselves to this style. They should identify who is responsible for the implementation. It may be helpful to ask IMRAs to draft the proposed action plans along with their recommendations. This has the advantage of increasing the likelihood of having realistic (and perhaps fewer) recommendations and also means that individual agencies can begin to implement necessary change at the earliest opportunity. The ORA may then be in a position to say in their report what action has already been taken.
The following headings could be used to turn recommendations into action plans:
Agency (which agency does this relate to if it is not an issue for the whole of the LSCB)
Recommendations (what is being recommended?)
Actions (what needs to be done)
Date (by when)
Lead (who is responsible)
Outcomes (these should be expressed in terms of effect not process. So an outcome for training on record keeping, for example, is not ”r;90 staff will have attended training” but ”r;record keeping will better reflect the voice of the child”.
Role of overview report author
Conversations with family members and staff are probably best done by the author though it may be appropriate for them to be accompanied by a SCR panel member. Staff conversations could be conducted in pairs, so that one person can take notes and both can debrief, and staff and family members could be invited to have a friend with them if they wish.
The meetings could be conversational in tone as ”r;a formal fact finding interview of the pseudo-legalistic kind is not well suited to the task of trying to see what the world looked like through someone else’s eyes” (SCIE page 9).
Notes from these conversations could be written up soon afterwards and sent, along with the reflections of the author to the relevant staff or family members inviting them to comment upon the accuracy of what has been written and to gauge their views of the comments of the authors.
It could be helpful to draw up a protocol between the individual agencies and the overview author regarding the role of the overview author if any disciplinary action arises from the SCR.
Overview report
Reference could be made to relevant research particularly the collation of findings of serious case reviews regularly provided by the Department of Children, Schools and Families, Scottish Government and the Welsh Assembly Government. A literature review could be commissioned by the Panel separately to the independent author. It is helpful to commission this at the beginning of the SCR process so that the review can inform the process. The review can be included in its entirety in the overview report, perhaps as an appendix, or it can be referenced throughout.
It is important that the overview report takes account of how the situation appeared at the time and is not hindsight biased. The writer does have the luxury of being able to comment with hindsight, they just need to be clear that that is what they are doing.
The overview report could have similar headings to the IMR but, with some additions.
Introduction
Story in summary
This need be no more than one page long but it makes the rest of the report easier to follow. It is here that it would be helpful to describe the family’s culture and, briefly, how members experienced their lives.
Family tree
Terms of reference
Methodology
List agencies involved, the roles of people on the SCR panel and the names of the LSCB chair, SCR panel chair and overview author. Make reference to any other investigations that have impacted upon the serious case review.
Family history in detail
This should tell the story chronologically drawing together all the information from the individual management reviews, case files, chronologies, reports and interviews. It is not necessary to comment upon these actions at this point.
The narrative should comment upon how often the child was seen and whether they were listened to.
Where an agency has had relevant contact with the alleged perpetrator, the chronology should also cover these actions and should ask whether everything was done which might reasonably have been expected to manage effectively the risk of harm posed by the alleged perpetrator to the child.
Questions identified by the review
During the process of reading the individual management reviews, chronologies, case files, reports and conversations with family and staff the writer should have drawn a list of questions in addition to the key issues identified in the terms of reference.
There should be some discussion as to why these questions have arisen.
Analysis
The analysis should address whether the incident was ‘predictable’ and ‘preventable’ as well as the key issues identified on the terms of reference and hopefully addressed in each IMR. It is likely that further themes will have emerged during the process of the review and these can be described as questions that the analysis can also address.
Working Together suggests that the following should be included in the analysis.
• Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?
• When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?
• 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?
• Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services?
• Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?
• Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?
• Were senior managers or other organisations and professionals involved at points in the case 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 with wider professional standards?
• Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?
• Was there sufficient management accountability for decision making?
Conclusion
The review process
Ofsted now require the independent overview author to comment upon the whole process. This should not be a repeat of what the process was but rather a consideration about how well it was done and include critically evaluating the effectiveness of the IMRs and addressing any shortfalls.
What do we learn from this case?
These could be listed as bullet points as they will form the basis of the recommendations. It may be helpful to group them in terms of
• National lessons
• Agency specific lessons
• LSCB lessons
Furthermore SCIE suggest taking an approach that looks at the underlying patterns of systemic factors. Their categorisation is:
1. Human-tool operation, how staff manage the computer systems and paperwork that they are required to use,
2. Human-management system operation, how staff respond to the management culture and supervision, resources,
3. Communication and collaboration in multi-agency working in response to incidents/crises (self explanatory)
4. Communication and collaboration in multi-agency working in assessment and longer term work (self explanatory)
5. Family-professional interactions, the relationships that workers make with family members
6. Human judgment/reasoning, staff’s ability to analyse, plan and reflect on those actions.
Good practice should also be included.
Recommendations
All single agency recommendations as well as those that have emerged in the overview report should be included. Working Together says these should be ”r;few in number”, this is rarely the case when all recommendations are included.
Appendices
These should include the joint chronology, any policies or procedures that have been found to be relevant and anything else deemed relevant but too long to include in the main body of the report.
The overview report should be fully anonymised (except for names of author, LSCB chair and independent chair of the SCR panel) by the time it is sent to Ofsted. However it can be helpful during the SCR process if names are used in the draft versions as this makes it easier for the panel to remember who is who.
Action plan
The responsibility for the action plan rests with the LSCB, not the overview author although the author may be invited to assist in its development. There should be a clear relationship between ”r;lessons learned”, ”r;recommendations” and ”r;action plan”. The following is an example:-
Lesson to be learned
The action plans were not agreed at senior management level so they remained pieces of paper rather than tools to improve the well-being of children.
Recommendation (written as an objective)
To ensure that individual SCR action plans are agreed at senior management level before they form part of the LSCB business plan.
Action plan
Agency LSCB
Recommendation To ensure that individual SCR action plans are agreed at senior management level before they form part of the LSCB business plan.
Action Redraft business planning guide
Date by 30/09/__
Lead Safeguarding officer
Outcomes Action plans will be owned by senior managers and implemented because they will be integrated into LSCB action plans.
Actions identified earlier in the process and already implemented should be included.
Monitoring
The action plan should contain details of how the implementation will be monitored. This plan could be incorporated into the safeguarding children board’s business plan to reduce the number of separate plans that are being implemented and to ensure the action plan has the support of the full Board.
Conclusion
The panel should ensure that the contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report, this could be included as an addendum. Working Together fails to suggest what should happen if these organisations or individuals are not satisfied and so I suggest that disagreements should be included in the overview report with content describing why there are differences of opinion.
Executive summary
This should include details of all those who sat on the Panel, though all should be anonymised except for the overview author, LSCB chair and independent chair of the SCR panel, and all recommendations, including single agency. The review process, key issues and action plan should also be included.
It should be written with pseudonyms for the family members, not identify geographical location and use professional titles (along with a number to differentiate between them) for staff members.
The summary should include an ”r;accurate reflection of all the main points”, Laming, (2009) and be written in narrative style. No acronyms or abbreviations should be used as this is a public document.
Dissemination
This could start at the beginning of the review process, not the end of it. Family members and staff who were involved in the case could be regularly updated about progress.
Consideration needs to be given to how staff who were involved in the case will be involved in dissemination. I now favour dissemination to all staff involved in small groups during the process. One group will be workers from agencies where the work completed on the case were largely positive. Other groups are agency specific and will include those workers whose agencies have most to learn from the case. I find that dissemination by the overview author and a Panel member before the overview report is completed allows for a high level of discussion and ownership. The report is usually influenced by these sessions as staff are able to give more context to the overview author.
It is common to run workshops for all other staff. There are no particular rules which need to be followed but sensitivity is required as workshops may include staff involved in the case. E-learning can be an effective addition to workshops. Although not interactive it does mean that staff joining the area some time in the future are more likely to have the learning disseminated to them.
LSCB action on receiving the serious case review report
‘The SCR sub-committee, on behalf of the LSCB, should quality assure the final SCR; that is, the IMR reports, the overview report, the executive summary and the action plan. The LSCB should approve the final SCR and:
• provide an anonymised copy of the IMRs, overview report, executive summary and the individual and multi-agency action plans and chronologies to Ofsted, the relevant GO Children and Learners Team, the SHA and DCSF. All personal information relating to children, family members and professionals involved in the case (with the exception of the names of the LSCB and SCR Panel chairs and the overview report author) should be anonymised in all the SCR documentation submitted to Ofsted and the relevant GO. If the child died in a custodial setting, copies of the anonymised SCR should be made available to the YJB and copies of the executive summary should be provided to the PPO;
• make arrangements to provide feedback and debriefing to staff and the media as appropriate;
• disseminate the executive summary and key findings to relevant interested parties;
• publish only the SCR executive summary once the SCR has been completed; (N.B. The LSCB should decide on a case by case basis when to publish the executive summary. In some, exceptional cases, where the publication of any summary might lead to identification of children or families the LSCB may have to keep the decision for a publication date under regular review.)
• implement those actions for which the LSCB has lead responsibility and monitor the timely implementation of the SCR action plan”.
Working Together to Safeguard Children, paragraph 8.44.
Appendix One
Guidelines for dealing with families where a tragedy has occurred
Introduction
These guidelines have been produced after a family was involved in a serious case review following the murder of two children by their father. They are based on guidance by the National Patient Safety Agency: Independent investigation of serious patient safety incidents in mental health services (2008).
First steps
Contact must be made with the family within 48 hours of the tragedy occurring. A designated senior individual with appropriate skills and experience should take the lead. They should agree with the caseworker whether it is most appropriate for the caseworker, their manager, or the senior manager to make contact with the family.
Next, the family should decide which family member or friend will be their main contact with the caseworker or manager and which members of the family should be included in the investigation. ’r;Family’ should be interpreted broadly and not necessarily be limited to parents or immediate relatives. In tragic circumstances family members may take positions about the tragedy which result in hostility between them, and strategies for handling this must be considered.
Principles of communications with the family
When an incident leading to serious harm or death occurs, the needs of those affected must be the primary concern of senior managers and those undertaking the investigation. All contact must be made in a respectful, dignified and compassionate manner.
The family will want to know:
• What happened?
• Why did it happen?
• How did it happen?
• What can be done to stop it happening to anyone else?
The basic approach which must underlie communication with the family is one of:
• Openness and honesty
• Timeliness and clarity
• Apology for any failures or mistakes made as soon as they are identified.
Meetings with the family
Family members should be offered an initial meeting, or separate meetings, depending on their wishes and the manager’s knowledge of their relationships. Where a parent has seriously harmed or murdered their child, family members should generally be met with separately, or in small groups, unless they all agree that it would be beneficial to meet together.
Meetings should not take place at the site of the incident. Staff directly involved in the case need not attend, though contact between them and the family should not necessarily be stopped. It should be explained at the meeting what support processes have been put in place, and how they can be accessed.
If family members initially reject contact, further attempts to establish contact should be made. If they do not wish to participate in the investigation, information should still be shared with them, for example in writing. If contact is still rejected, a referral for victim and family liaison should be considered.
Progress of the investigation
Victims, families and carers must be kept informed on the progress of the investigation. Specifically, they must:
• be informed as soon as possible, orally and in writing, of the purpose of the investigation (that is, to establish the facts), and how it is to be held
• have the opportunity to express any concerns they may have about the investigation process
• be consulted on the terms of reference for both internal and independent investigations
• be provided with the final terms of reference
• know how they will be able to contribute to the investigation
• be given access to the investigation’s findings prior to publication, and receive a copy of the final report and subsequent action plan
• be informed, with reasons why, if there is a delay in starting an investigation, or in the publication of the final report
• be offered media advice, should the media make contact with them.
Conclusion
This guidance deals with principles rather than detailed procedures, as every situation needs to be dealt with sensitively and individually.
To summarise, it is important in such cases:
• To plan contact with the family immediately
• To contact the family within 48 hours of the tragedy
• Not to prejudge who should and should not have contact with the family
• To ensure that a senior manager is responsible for overseeing contact with the family, and that the family meets them at some point
• To follow the principles of acknowledgement, truthfulness, timeliness, clarity of communication and apology throughout.
June 2010
