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									                                Safeguarding Children Policy Group

                     SERIOUS CASE REVIEWS

Compiled by the Safeguarding Children Policy Group consisting of members from:

Humber Mental Health Teaching NHS Trust
Hull and East Yorkshire Hospitals NHS Trust
Hull Teaching Primary Care Trust
East Riding of Yorkshire Primary Care Trust
Yorkshire Ambulance Service

Date: June 2007

Review Date: June 2009


INTRODUCTION                                                        2


INSTIGATING A CASE REVIEW                                           3-4

TIMING                                                              4-5


INDIVIDUAL MANAGEMENT REVIEW FLOWCHART                              7-8

THE MEDIA                                                           8

FORMAT OF MANAGEMENT REVIEW REPORT                                  8-9

OVERVIEW REPORT                                                     9

ACCOUNTABILITY AND DISCLOSURE                                       10

LEARNING LESSONS LOCALLY                                            10

LEARNING LESSONS NATIONALLY                                         10

REFERENCES                                                          10


APPENDIX 1 – CONSIDERATIONS FOR REVIEW PANEL                        11-12                                                       2

This document sets out a framework for the action that will be undertaken by the Health
family when the need to initiate a management review as required under ‘The Children Act
1989’ and ‘Working Together to Safeguard Children’ (HM Government 2006) has been
identified. This review will be known as a 'Serious Case Review' and the Local
Safeguarding Children Board (LSCB) will take lead responsibility. The Chair of the LSCB
has ultimate responsibility for deciding whether a Case Review should be instigated. If the
chair of the LSCB decides that a case should be subject to a Serious Case Review then a
Serious Case Review panel will be established involving at least Local Authority,
Children’s Social Care Services, Health, Education and Police.
The same principles and processes detailed here will be adopted when the need is
identified for a review of a particular case, which whilst not meeting the criteria for a
'Serious Case Review' does indicate that there may be practice or management issues
which require detailed scrutiny.
Working Together to Safeguard Children (2006) states:

          "When a child dies, and abuse or neglect are known or suspected to be a
          factor in the death, local agencies should consider immediately whether there
          are other children at risk of harm who need safeguarding (e.g. siblings, other
          children in institutions where abuse is alleged). Thereafter organisations
          should consider whether there are any lessons to be learnt about the ways in
          which they work together to safeguard and promote the welfare of children.
          Consequently when a child dies in such circumstances, the LSCB should
          always conduct a serious case review into the involvement with the child and
          family of agencies and professionals”.


          2.1 A Case Review should always be undertaken 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, irrespective of whether children’s Social Care is or has been
              involved with the child or family.

          2.2 Additionally, LSCB’s should always consider whether a serious case review
              should be conducted:-

                     •   where a child sustains a potentially life-threatening injury or serious and
                         permanent impairment of health and development through abuse or

                     •   has been subjected to particularly serious sexual abuse;
                     •   their parent has been murdered and a homicide review is being

                     •   their parent has been killed in a domestic violence situation;

                     •   the child has been killed by a parent with a mental illness;
                     •   the case gives rise to concerns about inter-agency working to protect
                         children from harm                                                                                 3
          N.B Any agency or professional may refer a case to the LSCB if it is believed that
              important lessons for inter-agency working can be learned from the case.


          3.1        The LSCB shall decide whether a case fits the criteria for being subject to the
                     serious case review process. This decision will be made using the criteria
                     identified above and with any information available from professionals
                     involved in reviewing the child’s death in accordance with the Child Death
                     Review Process (Chapter 7 of Working Together).

          3.2        Once the LSCB has decided that a case should be the subject of a serious
                     case review then a Serious Case Review Panel shall be established.

          3.3        The Primary Care Trust (PCT) should always inform the Strategic Health
                     Authority of every case that becomes the subject of a serious case review
                     whilst the Local Authority is required to inform the Ofsted (Office for
                     Standards in Education, Children’s Services and Skills).

                     3.3.1 The initial scoping of the review should identify those who should
                           contribute, although it may emerge, as information becomes available,
                           that the involvement of others would be useful. In particular,
                           information of relevance to the review may become available through
                           criminal proceedings.

                     3.3.2 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. Relevant independent professionals (including GPs)
                           should contribute reports of their involvement.
                           Designated professionals should review and evaluate the practice of
                           all involved health professionals and providers within the PCT area.
                           This may involve reviewing the involvement of individual practitioners
                           and Trusts and also advising named professionals and managers who
                           are compiling reports for the review. Designated professionals have
                           an important role in providing guidance on how to balance
                           confidentiality and disclosure issues. Where a children’s guardian
                           contributes to a review, the prior agreement of the courts should be
                           sought so that the guardian’s duty of confidentiality under the court
                           rules can be waived to the degree necessary.

                     3.3.3 The LSCB should commission an overview report which brings
                           together and analyses the findings of the various reports from
                           organisations and others, and which makes recommendations for
                           future action. The overview report should be commissioned from a
                           person who is independent of all the agencies / professionals
                           involved.                                                                                 4
          3.4        The Review Panel should consider, in light of each case, the scope of the
                     review process, and draw up clear terms of reference. Relevant issues to
                     include / consider are contained within Appendix 1.

4.      TIMING

          4.1        Within one month of a case coming to the notice of the LSCB Chair there
                     should be a review panel discussion to advise on whether a review should
                     take place and subsequently draw up clear terms of reference. Individual
                     agencies should secure case records promptly and begin work quickly to
                     draw up a chronology of involvement with the child and family.

          4.2        Reviews should be completed within a further four months, unless an
                     alternative timescale is agreed with the Ofsted Region 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 can not be
                     completed within four months of the LSCB Chair’s decision to initiate it, there
                     should be discussion with the Ofsted Region to agree a timescale for

          4.3        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
                     justices 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 conclude but this should not prevent early lessons learned
                     from being implemented.

          4.4        The LSCB should commission an overview report which brings together and
                     analyses the findings of the Individual Management Reviews and makes
                     recommendations for action.


          5.1 The Named / Designated Professionals for Safeguarding Children will
              undertake a Health Management Review of service involvement with the child
              and their family as soon as the decision is taken to proceed with the review
              and even sooner if a case gives rise to concerns within Health.                                                                                 5
                     It is imperative to include involvement from all services within health who have
                     had involvement with the child or family.

                     Those conducting the review or producing the overview report should not have
                     been directly involved with the child or family, or be the line manager or
                     supervisor of the professionals involved.

                     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. 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 responsible for ensuring that
                     recommendations are acted upon.

          5.2 Once it is known that a case is being considered for review, appropriate health
              records should on request be secured and forwarded to the Safeguarding
              Children Administration Team.

          5.3 The Designated professionals from each PCT will identify who will take the
              lead role in producing the health management review. The person
              undertaking this role will seek representation from each of the Trusts involved
              as appropriate.

          5.4 Staff and their representatives should be informed of what will be expected of
              them during the review process.

          5.6 A chronology should be completed detailing all involvement with the child(ren)
              and their family.

          5.7 The findings of the management review report should be ‘accepted’ by the
              Designated professionals from the appropriate PCT’s and shared with the
              relevant Trust Director with responsibility for safeguarding children, in order
              that he/she is able to make comments prior to the report being submitted to
              the LSCB.

          5.8 Upon completion of the health management review the Chief Executive within
              the appropriate Health Trust will be required ‘to accept’ the report and will be
              responsible for ensuring that any recommendations are acted upon, in
              partnership with the named professionals for safeguarding children for that
              Trust within the Clinical Governance arrangements for the Trust.

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

          5.10 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 (for example, alleged institutional abuse) disciplinary action                                                                                   6
                     may be needed urgently to safeguard and promote the welfare of other

          5.11 Where a child dies in a custodial setting (prison, young offender institution or
               secure training centre) the Prisons and Probation Ombudsman investigates
               and reports on the circumstances surrounding the death of that child. The
               investigation examines the child’s period in custody, including an assessment
               of the clinical care they received. The report would normally be made
               available to assist any serious case review process.


         Local Safeguarding Children Board (LSCB) receives request for Serious Case Review
                     (such a request can be made by any professional / agency)

  Decision to undertake a Serious Case Review is taken by the LSCB Chairperson and a Serious
                                Case Review Panel is established

The Designated Nurse for the relevant PCT area is informed of the decision to undertake a Serious
  Case Review and informs the Designated Doctor and all relevant NHS Trust Chief Executives,
              Health representatives on LSCB and the Strategic Health Authority
                               (via the Clinical Governance Lead)
              (See individual Trust flowchart for communication of SUI also)

  The Health Management Review commences. The nominated lead professional ensures:-
  •    ALL appropriate health records secured;
  •    Initial plan of action agreed with involved Trusts / named professionals;
  •    Agreement reached between Trusts and LSCB regarding media involvement;
  •    Appropriate personnel are allocated to undertake the review process with the nominated lead

  Nominated Lead Professional will:-
  •    Undertake the Health Management Review;
  •    Interview staff accordingly;
  •    Consult with Trust Managers / professional leads as appropriate;
  •    Complete a draft report / action plan once review completed;
  •    Seek ‘acceptance’ from relevant designated professional / director with safeguarding responsibility;
  •    Agreed outcomes / action plan shared with staff involved;
  •    Action plan shared with professionals whose role is to implement action plan’
  •    Outcome report / action plan disseminated to Trust Boards, Chief Executives, PEC’s, Clinical
       Governance, Risk Management Teams as appropriate.

      Health Management Review and action plan submitted to LSCB for inclusion in the Overview Report                                                                                            7
    Depending on the nature of the Serious Case Review there may be a delay in the publication by the
       LSCB of the overview report. This delay is usually as a result of on-going legal proceedings.

     Prior to LSCB publishing overview report ensure staff involved have feedback and de-briefing sessions as

       • Overview Report published alongside the action plan suggested by the Overview
          Panel and any additional recommendations made to respective agencies;

       • LSCB decide on a media strategy and involve representatives from individual
          agencies press offices;

       • Ensure an executive summary will be published by the LSCB;

       • Ensure ongoing system of monitoring and evaluating recommendations and action
          plans established by the LSCB;

       • Ensure the Named and Designated Professionals of each Trust to ensure that any
          additional recommendations / actions made by the LSCB Overview Panel are
          addressed in updated action plans.

7.      THE MEDIA

The Health Trusts involved in a Serious Case Review should not make any comments to
the media prior to the publication of the Overview Report by the LSCB. All press releases
should be issued in consultation with the LSCB and the Trusts Communication Teams.


•     What was our involvement with this family ?

      Construct a comprehensive chronology of involvement, detail services offered,
      summarise decisions reached and actions taken.

•     Analysis of Involvement

      Consider the events that occurred, the actions taken, or not. Where judgements
      made, or actions taken which indicate that practice or management could be improved
      ? Try and get an understanding not only of what happened, but why.

      Consider specifically:

          -          Were practitioners sensitive to the needs of the children in their work,
                     knowledgeable about potential indicators of abuse or neglect, and what to do if
                     they had concerns about a child ?                                                                                          8
              -          Were there policies and procedures in place for safeguarding 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 ? Where
                         appropriate services offered/provided or investigations made in the light of
                         assessments ?

              -          Where relevant, were appropriate child protection or care plans in place, and
                         child protection and/or looked after children processes complied with?

              -          When and in what way, were children's wishes and feelings ascertained and
                         complied with ? Was this information recorded ?

              -          Were practices sensitive to the racial, cultural, linguistic and religious identity
                         of the child and family ?

              -          Were more senior managers, or other agencies and professionals involved at
                         points where they should have been ?

              -          Was the work in this case consistent with agency and LSCB policy and
                         procedures for safeguarding children and wider professional standards?

    •    What do we learn from this case ?

          Is there good practice to highlight, as well as indicators of where practice could be
          improved? Are there implications for training, management and supervision. Working
          in partnership, resources?

•         Recommendations for action

          What action should be taken and by whom? What outcomes should these actions
          bring about, and how will the agency review whether they have been achieved?


    Upon receipt of the Health Internal Management Report, the LSCB Review Panel will
    produce an Overview Report. This report will bring together and relate all the information
    and analysis contained in the individual management reports together with the analysis of
    the LSCB Review Panel. An action plan will be produced and a copy of the report will be
    sent to the Department for Education and Skills (DfES) (SSI Social Care region).                                                                                         9
    JANUARY 2008

The LSCB, in consultation with relevant agencies will need to consider carefully who
should have access to the Overview Report, taking into account the tensions between the
need for confidentiality for the child/family and the need for public bodies to demonstrate

The LSCB will produce an anonymised executive summary that will be made public.


         11.1 The review should be conducted in such a way as to be a learning exercise
              rather than a trial or ordeal for those involved. Recommendations should be
              specific and achievable. The LSCB will audit recommendations and actions.

         11.2 Organisational practice should include a culture of auditing and reviewing.
              Record keeping and recording that is systematic and clear will assist the review
              as will a good understanding about the roles and responsibilities of all
              professionals working with children, young people and their families.

         11.3 The lessons learned from Serious Case Reviews will be disseminated across
              the whole Health family.


The Department for Education and Skills (DfES) is responsible for identifying and
disseminating common themes and trends that arise in these reviews. Key findings are
identified along with implications for policy and practice and this is fed back into the LSCB
to inform local policy procedure and practice.


     •    Working Together to Safeguard Children. HM Government 2006.

     •    Complex Child Abuse Investigations Inter-agency Issues. Home Office /
          Department of Health, 2002.

     •    The Children Act 1989.

     •    The Children Act 2004                                                                          10

This guidance will be monitored through audit of the safeguarding standards.


An equality and diversity impact relevance assessment has been undertaken and the
guidance does not require a full equality and diversity impact assessment.                                                                  11
                                                                                  APPENDIX 1

                           CONSIDERATIONS FOR REVIEW PANEL

•         what appear to be the most important issues to address in trying to learn from
          this specific case ? How can the relevant information best be obtained and

•         who should be appointed as the independent author for the overview report?

•         are there features of the case which 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 review panel to bring in an outside expert at any stage, to shed
          light on crucial aspects of the case?

•         over what time period should events be reviewed, i.e. how far back should
          enquiries cover, and what is the cut-off point? What family history / background
          information will help better to understand the recent past and present?

•         which organisations and professionals should contribute to the review,
          including, where appropriate, for example, the proprietor of independent school,
          playgroup leader should be asked to submit reports or otherwise contribute?

•         how should family members contribute to the review and who should be
          responsible for facilitating their involvement?

•         will the case give rise to other parallel investigations of practice, for example,
          independent health investigations or multi-disciplinary suicide reviews, a homicide
          review where a parent has been murdered, a Youth Justice Board (YJB) Serious
          Incident Review and a Prisons and Probation Ombudsman investigation where the
          child has died in a custodial setting?

•         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

•         is there a need to involve organisation / professionals in other LSCB areas and
          what should be the respective roles and responsibilities of the different LSCB’s with
          an interest?

•         how should be review process take account of a Coroner’s inquiry, and (if
          relevant) any criminal investigations or proceedings related to the case? How best
          to liaise with the Coroner and/or the Crown Prosecution Service?

•         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?

•         who will make the link with relevant interests outside the main statutory
          organisations e.g. independent professionals, independent schools, voluntary
          organisations?                                                                             12
•         when should the review process start and by what date should it be completed?

•         how should any public, family and media interest be managed, before, during
          and after the review?

•         does the LSCB need to obtain independent legal advice about any aspect of the
          proposed review?

Some of these issues may need to be re-visited as the review progresses and new
information emerges.                                                                        13

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