General Principles for Case Reviews
The following principles should underpin the execution of serious case reviews.
Agencies should take action immediately and follow this through as quickly as possible.
Those conducting reviews should not have been directly concerned with the child or family.
All important factors should be considered and there should be an opportunity for all those involved to contribute.
There should be no suspicion of concealment.
Due regard must be made to the balance of individuals rights and public interest.
Close collaboration between all the agencies involved is required.
Action should be taken to implement any recommendations that may arise and are accepted by the agencies concerned.
Where 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 for conducting any review. Any other LSCBs 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 any review, again involving other LSCBs with an interest or involvement.
Instigating and determining the scope of a Case Review
South West LSCBs have standing Serious Cases Review Sub-groups. The membership of these sub-groups is made up of representatives from children’s social care, education, health, police, probation and the NSPCC (it is a requirement of Working Together 2010 that those agencies indicated in bold are involved in assessing the need for a serious case review).
In making this decision where a child has died, the Chair should draw on information available from the professionals involved in reviewing the child’s death (see Working Together 2010, Chapter 7 for details of the new child death review processes). Conversely, the child death review process may provide the trigger for a serious case review.
Functions of the Serious Case Review Sub-group
To consider, at the request of the Chair of the relevant LSCB, whether a serious case review should take place, and to make recommendations to the LSCB Chair, who has ultimate responsibility for deciding whether or not such a review should be conducted. Such recommendations should detail:
- the level and type of review that is indicated.
- whether the investigation could be carried out by one or two agencies or whether a full serious case review overview panel is required.
- the agency membership and chair for the overview panel.
- who should chair the overview panel.
To determine, in the light of each case, the scope of the review process, and, as far as possible draw up clear terms of reference. (If a serious case review takes place, the first meeting of the Overview Panel will ratify and, if necessary, make additions or amendments to the terms of reference.) Relevant issues may include:
- what appear to be the most important issues to address in identifying learning from the case?
- how can the relevant information best be obtained and analysed?
- what should be the start and completion dates bearing in mind the timescales?
- over what time period should events be reviewed, i.e. how far back should records be examined, and what should be the cut-off point? What family history/background information will help better understand the recent past and present which the review should try to capture?
how should the child (where the review does not involve a death), surviving siblings, parents or other family members be invited to contribute to the review and who will facilitate 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 agencies and professionals should be asked to submit reports or otherwise contribute to the review, (e.g. proprietor of independent school, or playgroup leader) should contribute? It should be noted that, as information becomes available during the review, it may be necessary to seek the contribution of agencies who had not initially thought to have a significant role in relation to the case. In particular, information of relevance to the review may become available through criminal proceedings.
- who will make the link with relevant interests outside the main statutory agencies, for example independent professionals, independent healthcare providers or voluntary organisations?
- is there a need to involve agencies/professionals in other LSCB areas (see 00 Page377), 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 or bring in an outside expert at any stage, about any aspect of the review?
- who should be appointed as the independent author for the overview report (as this cannot be the Chair of the LSCB, the SCR sub-committee or the SCR Panel)
- will the case give rise to other parallel investigations of practice, (e.g. independent into 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 Fatal incident Investigation where the child has died in a custodial setting or a Serious Further Offences or MAPPA Serious Case Review where offenders charged with further serious offences whilst subject to statutory supervision) and if so, how can a co-ordinated or jointly commissioned review process best address all the relevant questions which need to be asked, in the most economical way? Arrangements should also be agreed locally on how a NHS Serious Untoward Incident investigation into provision of healthcare should be co-ordinated with a serious case review.
- how should the serious case review process fit in with the processes for other types of reviews, e.g. for homicide, mental health or prisons?
- how should the review process take account of a coroner’s enquiry, any criminal investigations or other civil court proceedings related to the case? How best can the LSCB liaise with the Coroner and/or Crown Prosecution Service 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 undertaken by the LSCB?
- how should any public, family and media interest be managed, before, during and after the review? In particular, how should surviving children, where appropriate, and family members be informed of the findings of the SCR? Who will provide a link between the overview panel and the LSCB Media Sub-group?
- does LSCB need to obtain independent legal advice about any aspect of the proposed review?
- are there features of the case that indicate that any part of the review process should involve, or be conducted by, a party independent of the professionals/organisations who will be required to participate in the review? Might it help the overview panel to bring in an outside expert at any stage, to shed light on crucial aspects of the case?
N.B. Some of these issues will need to be re-visited as the review progresses and new information emerges. The terms of reference may need to be revised and agreed by the LSCB Chair.
Smaller scale audits
In some cases, it may be valuable to conduct individual management review or smaller scale audits of individual cases which give rise to concern but which do not meet the criteria for a full serious case review. In such cases, arrangements should be made to share relevant findings with the LSCB.