Multi Agency Case Management Reviews · Web viewThe referral form, or SCR1 is attached as Appendix 2. The SCR1 must provide enough information to enable the SCRG to assess whether

NSCB

Serious Case Reviews

Process & Guidance Notes

OCTOBER 2013

SCR Processes & Guidance 1

TABLE OF CONTENTS

1. Introduction

2. Serious Case Review Group

3. Criteria and Referrals

4. Requirements and Freedoms

5. Proportionate Reviews

6. Systems Methodology & Learning Together

7. Reviewers & Review Panel

8. Engagement with Learning: Professionals & Families

9. Timelines and processes

Phase 1: Establishing scope and parameters of the reviewPhase 2: Analysis and EngagementPhase 3: Report PublicationPhase 4: Disseminating Learning

10. Timeline Flow Charts

11. Composite Action Plan

12. National Panel of Experts

Appendices

Appendix 1: Munro: What is a Systems Approach?Appendix 2: SCR1: Referral FormAppendix 3: Template letter to Heads of AgencyAppendix 4:` Agency heads contact detailsAppendix 5: Template letter to Professionals Involved in CaseAppendix 6: SCIE Conversation Structure SummaryAppendix 7: Template letter to FamiliesAppendix 8: Medical Consent FormAppendix 9: National Panel of Experts instructions


1. Introduction

In March 2013, the government released the revised version of Working Together to Safeguard Children, (Working Together 2013) which sets out the ways in which organisations and individuals should work together to safeguard and promote the wellbeing of children. This guidance came into effect on 15 April 2013, including stricter criteria for Local Safeguarding Children’s Boards’ to conduct Serious Case Reviews.

Chapter 4 of Working Together 2013 sets out the principles of learning and improvement and clearly states:

Local Safeguarding Children Boards (LSCBs) should maintain a local learning and improvement framework which is shared across local organisations who work with children and families. This framework should enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result. (Chapter 4, paragraph 3).

Within this, there is a strong focus on serious case reviews (SCRs) and clear direction from the government that SCRs should be undertaken regularly. The requirement for SCRs is set out in regulation 5 of the Local Safeguarding Children Boards Regulations 2006. Guidance under Working Together 2013 outlines both new requirements and new freedoms in the process of conducting SCRs. This was in response to the Munro Review of Child Protection, which argued that the findings of SCRs under the previous guidance were often repetitive, focussed too strongly on the conduct of individual professionals, and included insufficient analysis on the impact of the wider systems and structures operating around the case.

Professor Munro recommended that all future SCRs should be undertaken using systems methodology, which moves away from the specific features of an individual case to consider the deeper, underlying issues that influence multi-agency practice more generally. In a paper published Feb 2012 (attached as Appendix 1), Munro clarifies what she means by taking a systems approach, i.e. ‘The crux of a systems approach as developed in health, aviation, and engineering is that it examines human performance in its context and recognises that people’s competence in carrying out tasks to a high standard is influenced by the whole system around them.’. See also Section 3, Systems Methodology & Learning Together, below.

2. Serious Case Review Group

Working Together 2013 is statutory guidance and therefore must be followed unless there are very good reasons not to do so.

The Norfolk Safeguarding Children Board (NSCB) includes a number of subgroups including the Serious Case Review Group (SCRG). The SCRG meets on the second Monday of every month to consider cases. Members of the group include representatives from: Probation (Director of Public Protection & Chair of SCRG) Children’s Social Care (the Independent Chairing Service Manager) Health (Norfolk’s designated doctor and nurse) Police (Detective Superintendent, Vulnerability & Partnerships Command) Education (Safeguarding Adviser)


nplaw (Solicitor and Legal Adviser to the SCRG) NSCB (Business Manager & Monitoring & Evaluation Officer)

The NSCB Chair also attends and meetings are supported by the SCR Business Support Officer.

Meetings are quorate if attended by five persons to include representatives from children’s services and health.

3. Criteria and Referrals

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

5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where:

(a) abuse or neglect of a child is known or suspected; and (b) either —

(i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

Working Together 2010 provided guidance that a child can be seriously harmed in the following situations:

A child sustains a potentially life threatening injury or serious and permanent impairment of physical and/or mental health or 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 under the Domestic Violence Act 2004; or

A child has been seriously harmed following violent assault perpetrated by another child or an adult.

Cases which meet one of these criteria (i.e. regulation 5(2)(a) and (b)(i) or 5 (2)(a) and (b)(ii) above) must always trigger an SCR.

In addition, an SCR should always be carried out when a child dies

in custody in police custody on remand or following sentencing, in a Young Offender Institution, in a

secure training centre or a secure children’s home, or where the child was detained under the Mental Health Act 2005.

Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide and abuse or neglect is known or suspected. .


Where a case is being considered under regulation 5(2)(b)(ii), unless it is clear that there are no concerns about inter-agency working, the LSCB must commission an SCR.

The Local Authority has a duty to notify Ofsted and the Department for Education (DfE) of cases in which abuse or neglect is known or suspected and either:

A child has died A child has suffered a potentially life threatening injury, serious sexual abuse,

or sustained, serious and permanent impairment of health and development.

In any such case, the Local Authority should also notify the NSCB’s SCRG, using the SCR1, referred to below.

The final decision on whether to conduct the SCR rests with the LSCB Chair. The SCRG has devised a referral form, SCR1, to enable referrers to put forward the case for conducting a review based on these criteria. Critically, the SCRG need information from more than one agency to make judgements about whether there is cause for concern about the way agencies worked together and the impact that had on the way the case was handled prior to the serious harm. The referral form, or SCR1 is attached as Appendix 2. The SCR1 must provide enough information to enable the SCRG to assess whether the grounds have been met i.e. in what way the death/serious harm is related to abuse/neglect and, in relation to Regulation 5(2)(b)(ii), the nature of the serious harm and the nature of the concern about working together to safeguard children.

SCR1 also enables the SCRG and NSCB Chair to track the actions leading to a decision being taken on whether or not to conduct a review.

Referrers should consult with their agency lead sitting on the SCRG before submitting an SCR1. If the referrer’s agency is not represented, the referrer should contact the NSCB Business Manager.

The guidance is clear that reviews should happen regularly (Chapter 4, paragraph 8). In addition to cases that meet the SCR criteria, different types of review can include: child death review - of all child deaths up to the age of 18 (covered under Chapter

5 of Working Together 2013); review of a child protection incident which falls below the threshold for an SCR; review or audit of practice in one or more agencies.

If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or an alternative form of case review. The SCRG will commission reviews of cases which do not meet the criteria for an SCR, but which can provide valuable lessons about how organisations are working together to safeguard and promote the welfare of children. Although not required under Working Together 2013 these reviews are important for highlighting good practice as well as identifying improvements which need to be made to local services. Such reviews may be conducted either by a single organisation or by a number of organisations working together. LSCBs should follow the principles of systems methodology when conducting these reviews.

The SCR1 seeks views from the referrer for other types of review to take place. The NSCB Business Manager is responsible for notifying the referrer of the decision taken by the SCRG and Chair.


4. Requirements and Freedoms

The new guidance brings both more requirements and more freedoms to the process of conducting SCRs.

Requirements

Requirements for LSCBs are:

To create and maintain a Learning and Improvement Framework To conduct an SCR in cases which were previously discretionary To conduct more regular reviews than those meeting the SCR criteria To conform to systems principles in the conduct of case reviews and SCRs To publish final SCR reports To ensure that the process is timebound and takes no more than six months, or

on conclusion of any court proceedings

This document, along with the NSCB’s performance framework, is a key element to Norfolk’s Learning & Improvement Framework. The Framework in full lays out how a culture of continuous learning and improvement will be promoted across the organisations that work together to safeguard children, identifying opportunities to draw on what works and promote good practice

Historically, Norfolk has conducted on average one or two discretionary reviews annually where cases may have met the SCR criteria, but a child has not died. The criteria have now changed and where these cases were previously discretionary, they will now be subject to the full SCR processes. (See criteria, below). Chapter 4 of Working Together 2013 makes it clear that as part of a wider framework of learning and development, LSCBs should include management reviews on cases that do not meet the SCR criteria, or reviews of cases where practice was particularly good, with LSCBs free to decide how best to conduct these reviews. This framework includes the existing requirement for LSCBs to ensure that a review is undertaken for each death of a child who is normally resident in their area, through a separate Child Death Overview Panel.

Working Together 2013 is also clear that transparency is a key element of this process, and reemphasises the requirement that SCR reports must be published in full. Notably, previous guidance included a caveat that this requirement must be adhered to “unless there are compelling reasons” for this not to happen: this caveat has now been removed, and the Government is clear that reports must be written with publication in mind and “without needing to be amended or redacted”. Working Together 2013 clarifies that publication means, at a minimum, publishing the report on the LSCB’s website for a minimum of 12 months, and to make it readily available thereafter.

Freedoms

While the government is clear that they want to increase the number of SCRs that are initiated and published in order that, nationally, lessons can be learned to drive up the quality of child protection services and avoid mistakes being repeated, the new guidance does also allow for more freedoms. From April 2013 LSCBs are free to decide: the process/methodology to use what is a proportionate response for any particular SCR


Working Together 2013 is clear that LSCBs may use any learning model which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munro, however it is not prescriptive. Norfolk’s recent experience of using this approach in discrete multi-agency reviews, means we are well placed to introduce systems methodology in the development of our SCR processes.

The concept of a proportionate response also allows for some discretion depending on the scale and level of complexity of the issues being examined. This guidance allows for a range of responses and guidance on deciding what is appropriate for the cases to be reviewed.

5. Proportionate Reviews

Working Together 2013 states that the SCR should be proportionate according to the scale and level of complexity of the issues being examined.

The SCRG - with the approval of the NSCB Chair - must therefore decide what scale of SCR is proportionate to enable learning while at the same time ensuring that all reviews are conducted in a way in which: recognises the complex circumstances in which professionals work together to

safeguard children; seeks to understand precisely who did what and the underlying reasons that led

individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and

organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings.

The table below lays out three different options for conducting a review:

SCALE RATIONALE Approx cost* Summary of process

FULL

The case may: include more than one

child or family take place over an

extended period of time have multiple agency

involvement have multiple and

complex forms of abuse result in the death of a

child attract media attention

£24 - £26k

2 reviewers 6 meetings, incl. scoping

day, structured conversations and professional learning day(s)

Interviews with family (optional)

Report writing, including one full report/analysis of Key Practice Episodes and a second systems analysis report with minimum detail for publication

Report presentation to SCRG


SCALE RATIONALE Approx cost** Cost breakdown

MEDIUM

The case may: have features of a full

review, but the degree of serious harm or long term impairment cannot be ascertained at the point of commissioning the review

have features that have been identified in previous cases

£12 - £15K

1 or 2 reviewers 4 - 5 meetings, incl.

scoping day, structured conversations and professional learning day

Interviews with family (optional)

Report writing and presentation to SCRG

FOCUSED

The case may: have been picked up within

a reasonable time frame, limiting the effects of serious harm

have no more than three agencies involved


1 reviewers 2 meetings 1 professional learning day Report writing and

presentation to SCRG

All reviews will:

be conducted by independent reviewers trained in systems methodology, ideally with SCIE;

have full and comprehensive chronologies to support learning; and as a minimum, include professionals in a learning workshop so that frontline

staff have the time to reflect on systems, determine why things happened as they did and shape recommendations for improving practice

Costs have no bearing on the type of review that is commissioned. The response will be proportionate to the complexities of issues identified at SCRG and scoping.

6. Systems Methodology & Learning Together

The Social Care Institute for Excellence (SCIE) have been leading thinkers in the development of systems methodology and have developed a ‘Learning Together’ model of review, in collaboration with Professor Eileen Munro. This model can be adapted according to the scale and complexity of cases that meets the criteria for an SCR. The Learning Together model’s key features meet the standards laid out in Working Together 2013, namely:

Frontline staff and managers are directly involved and have a constructive experience

Children, young people and family members have their say and are kept in the picture

Change starts to occur early on in the review with participants altering their practice

Analysis unpicks problems to reveal the norms and drivers behind them The findings are owned at a senior level, across agencies


The report enables LSCBs to take action and to hold member agencies to account

Transparency allows public accountability without jeopardising the anonymity of family members or professionals.

The changes in practice generated provide better support to frontline workers in their work to improve outcomes for children

In addition, SCRs should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.

7. Reviewers & the Review Panel

Norfolk has had considerable success using the SCIE methodology in recent multi-agency reviews. SCIE has a pool of accredited reviewers from which we would recruit a lead for our SCRs.

Under these reviews, the Independent Reviewers have been supported by a local Review Panel which included representatives from all agencies involved in the case. This systems methodology will continue.

Working Together 2013 clearly states that SCRs should be led by individuals who are independent of the NSCB and of the organisations involved in the case. The NSCB will consider training to officers in a range of organisations and agencies in Norfolk in systems methodology so that it has a pool of reviewers within Norfolk to meet these expectations.

The role of the Independent Reviewer (s)

The Independent Reviewer(s) (the IR(s)) are responsible for leading the SCR. This includes:

chairing the Review Panel meetings and setting the agenda for each meeting to ensure that the SCR is kept within timescales

agreeing the terms of reference for the SCR with the Review Panel Members at the initial scoping meeting

agreeing the key practice episodes with the Review Panel conducting interviews with family members (if appropriate) planning and facilitating the professional learning workshop day writing the SCR report to required specification Producing an internal analysis of key practice episodes in addition to the

report for publication which will focus on systems ensuring recommendations are SMART presenting the report to the SCRG and/or the NSCB

In full reviews, two IRs will be appointed. The lead IR will take overall responsibility for the report writing and the second IR will support with chairing workshops, interviewing and workshop preparation. For example, the first Lead Reviewer might do 20 days work, and the second LR about 12 days. SCIE contributes 2-3 days in supervision and QA.

In medium and focused reviews, one IR will be appointed.

The NSCB Chair will appoint the IR(s).


The role of the Review Panel

The Review Panel will be made up of managers from the agencies involved in the case. The managers must have had no line management responsibilities in respect of the case and no other involvement that might lead to a conflict of interest. The Heads of Agency (HoA) from the managers’ respective agencies must agree to release them for the days required to conduct the review. A copy of the letter sent to the Heads of Agency at the start of the process is attached as Appendix 3.

NB The Head of Agency is not necessarily the NSCB Board Member: in some cases this role will be higher, for example, within Police the Board Member is the Chief Superintendent, but the Chief Constable will be notified. This is because the people at the very top need to be informed in the event of media interest. Where this is the case, the Board Member will also be copied into correspondence to ensure that the strategic leads at all levels are kept informed. The SCR Administrator keeps a log of contacts in the template letter file. (Appendix 4, accurate as of Sept 2013, but to be checked at each case and updated as required.)

The Review Panel will be responsible for:

agreeing the scope of the review which will underpin the terms of reference for the review

compiling the records from their own agencies and contributing to the chronology attending all meetings and agreeing the key practice episodes with the

Independent Lead conducting one-to-one conversations with professionals involved in the case, and

their line managers, and writing up the notes of those conversations conducting interviews with family members (optional) contributing to the findings and analysis preparing professionals for the learning workshop day, including providing

support following the workshop if required ensuring the final report is shared with all professionals involved in the case contributing to the action plan that is devised from the recommendations

The NSCB Business Manager will project manage the process, including pulling together the chronology, with the support of the SCR Administrator. All SCRs are included on an action log held by the SCR Administrator. Dates and progress are monitored regularly and reported to the SCRG. Issues will be escalated to Heads of Agencies if necessary.

See also section on Timelines and Processes below.

Heads of Agencies

The Heads of Agencies will identify staff to sit on the Review Panel. The NSCB Business Manager and SCR Administrator will ensure that the Review Panel meetings are agreed and timetabled as quickly as possibly and in line with the timeframes outlined below, once the Panel has been agreed.

8. Engagement with Learning: Professionals & Families


Key to understanding why things happened in an SCR is the involvement of professionals and, where possible, families. Working Together 2013 is clear that:

professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;

families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

Professional involvement

The purpose of an SCR is to ensure that learning is collaborative: it is a multi-agency process throughout with an emphasis on learning rather than blaming (with the caveat that weak and poor practice is named and appraised and a recognition that agencies undertake due diligence reporting when necessary).

In order to ensure that communications and processes support effective engagement with professionals, the SCRG have developed a number of tools and techniques as follows:

at the start of the process Review Panel Members will be asked to approach professionals involved in the case and provide a letter from the NSCB Chair setting out the methodology, the dates and the expectations of their involvement in the review process. (Appendix 5). This should be sent along with a copy of this guidance.

Review Panel Members will meet with the professionals when accessing their records and agree a time for one to one conversations. These conversations will be conducted using the principles of the Learning Together Model. The conversation structure is attached as Appendix 6. (NB if the review is focussed, this step may be omitted).

Review Panel Members will also confirm with professionals throughout the process that they will be asked to contribute to the professional learning day workshop.

NB. The purpose of SCRs is to engage professionals in learning and analysis. If competency issues arise in respect of individuals that have not already been addressed by the relevant agencies , these will be directed by the SCRG to the agencies involved.

When a child/children have moved into Norfolk from out of county and there is cause to believe that the relevant Local Authority where they resided prior to the move did not safeguard them effectively, the Board Manager will contact the corresponding LSCB and advise them of the case. This will be done as early as possible in the review process. Where appropriate, the other Local Authority will be invited to the scoping meeting and asked to provide information.

Family involvement


There is good evidence to show that family’s involvement in the SCR process contributes effectively to learning. In full and medium reviews early consideration should be given to ensure that time and resources are allocated to interviewing family members, including – where appropriate – any siblings. This will not only ensure that SCRs are child centred, but will also enable the IR to accurately reflect what it was like to be a child in that family.

The purpose of the interview with families is to ascertain what engagement they had with services and their perspective on the safety of the children leading up to the incident(s) that triggered the review. A copy of the letter sent to parents/carers is attached as Appendix 7. Variations of this letter should be considered if the review would benefit from involvement of extended family, such as grandparents. Panel Members should seek advice about ways to communicate with children depending on their age and levels of understanding.

NB At the time of writing the legal requirements for asking for consent to view medical records was still under review. In some circumstances it is anticipated that consent will not be required.

The involvement of parents/carers also provides an opportunity to request permission for access to adult medical records in case the adults’ health had any impact on the case. This needs to come from Health colleagues, i.e. the Norfolk & Waveny Designated Safeguarding team. A template consent form is attached as Appendix 8.


9. Timelines and Processes

Timelines will vary depending on the scale of the SCR. There is however, an overriding expectation that all SCRs will be completed within six months of notifying Ofsted, the DfE and the National Panel of Experts (the National Panel). See Section 14 below for more information relating to the National Panel.

The table below outlines the predicted time required for each type of review: full, medium and focused.

SCALE ScopingMeeting

No. of meetings

Prof workshop Notes on time requirements

FULL Half a day 2 x half day4 x full day

2(1.5

days)

Also need to allow time for: collating records

(chronology) structured conversations Report writing (Reviewer

only)MEDIUM Half day 4 1 - 2 As above

FOCUSED N/A 2 1

The SCRG will determine the scope of the review on commissioning. As with full and medium reviews, time needs to be allowed to collate a chronology to support analysis.

Focussed reviews will not involve structured conversations but Review Panel Members will be expected to meet before and after the professional learning day to discuss KPEs and findings

See also section 10, below, on timelines flow chart for each type of SCR.

Before any SCR is considered, the NSCB Business Manager needs to confirm with Police about the legal status of the case, i.e. Police are requested to identify any ongoing criminal proceedings. This may influence the timescales – particularly the publication of the SCR report - and the National Panel of experts must be advised. If delays occur because of criminal proceedings, every effort should be made while the SCR is in progress to: (i) capture points from the case about improvements needed; and (ii) take corrective action. Where a case is still in criminal proceedings, the NSCB Business Manager will liaise with the Police’s Senior Investigating Officer and ensure that all interested parties, i.e. the SCRG, the NSCB Chair, the Review Panel and the National Panel are kept informed of the outcomes.

The process for conducting all reviews can be broken down into four distinct phases:


Phase 1: Establishing scope and parameters of the review

Chair agrees SCR. This decision should normally be made within one month of notification, i.e. receipt of the SCR1.

The final decision rests with the Chair of the NSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process.

NSCB Business Manager identifies an IR(s)

Appointment of IR(s) by the Chair

Chair notifies the National Panel providing details of the case.

Deadline identified for publishing report identified based on starting date of commission. The starting date will be on acknowledgement from the National Panel or within ten working days of notification.

On agreement from the National Panel, HOA are notified: a date for scoping meeting is set (if required) and HOA are requested to identify Review Panel Members. The relevant SCRG member is copied into this e-mail for information and to support early identification of Review Panel member if appropriate.

In respect of full and medium SCRs, Review Panel has its initial ‘scoping’ meeting which will take between 3 and seven hours, depending on the complexities of the issues and/or how long the safeguarding concerns were present prior to the case being triggered. The purpose of the scoping meeting is to:

o Set time parameters around the chronologyo Agree the terms of reference (TOR)o Identify any gaps in terms of agency involvemento Consider how to involve the family o Confirm with agencies that the review is going aheado Set dates for any subsequent meetings, including the professional

learning day workshopo Agree a deadline for collating the chronology

The NSCB Business Manager will arrange a scoping meeting as soon as possible after the SCR is commissioned or within five working days of notifying the HOAs. The scoping meeting will be held within two weeks or ten working days of the letter going out.

In respect of focused SCR, SCRG will determine the scope of the review; the TOR will be drafted by the Business Manager, in consultation with the Independent Reviewer in line with the scoping provided by the SCRG. Dates and deadlines will be agreed and communicated by e-mail between the NSCB Manager and the Review Panel, with an option for a meeting available if Panel Members require it.

Review Panel Members will confirm that all current and previous practitioners who are involved with the child and family/extended family are aware of the review and its purpose. This includes making initial contact with professionals involved with the case, agreeing a time to access records and advising them, and their managers, of dates for structured conversations (if appropriate to scale of review) and the professional learning day workshop

For full SCRs, the Lead Reviewers and Review Panel will also agree which professionals to include in the Case Group, i.e. the professionals who need to be


involved in the learning and analysis and attend the workshop days. At the end of phase 1, the first of two workshops will be scheduled to clarify systems methodology and provide an opportunity for all practitioners to prepare for Phase 2. The first workshop will be half a day.

The deadline for collating a chronology will be set within 25 working days from the starting date of the SCR commission.

All aspects of Phase 1 will be adhered to regardless of the scale of the SCR, with the exception of the scoping meeting which may not be necessary for a focussed review.

Phase 2: Analysis & Engagement

The purpose of Phase 2 is to draw out the key practice episodes and analyse the systemic influences that can tell us why things happened as they did. The chronology will pull together the story of the child. In addition to this, the review process will:

the IR(s) and Review Panel will have at least one meeting to consider the chronology before the structured conversations take place

allow time for undertaking the structured conversations with professionals involved in the Case Group and share the outcomes of these conversations at subsequent meetings ahead of the professional learning day workshop

explore the key practice episodes and undertake preliminary analysis of systemic influences, including behaviours and other contributory factors in subsequent meetings so that the Lead Reviewer(s) and Review Panel can plan the workshop and set the agenda

enable professionals in the Case Group to discuss themes emerging at the workshop and provide opportunities for frontline staff to comment on the accuracy of the preliminary analysis, consider the case from a multi-agency perspective and contribute to shaping the recommendations (see also section 9, above).

result in an internal report on key practice episodes which provide details on the case. The length of this document will depend on the size of the review, for example, in a full or medium review there will be a full narrative, however, in a focussed review, this will be a briefer analysis drawn from the chronology and the meeting with professionals.

result in a draft report for publication, written by the IR, following the workshop. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.

SCR reports must:

o provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;

o be written in plain English, avoiding acronyms, and in a way that can be easily understood by professionals and the public alike; and

o be suitable for publication without needing to be amended or redacted.

The report will be published and therefore should take into account the requirement of the Data Protection Act, the common law duty of confidentiality, and the European Convention on Human Rights and must be drafted to avoid


harm to the welfare of any children or vulnerable adults involved in the case. The legal adviser to the SCRG must be asked to advise on these issues.

The number of meetings required ahead of the workshop will determine the scale of the review: the number of agencies involved, the length of time that the case covers and the impact that it had on the child/children in question will provide indicators of the complexities of the safeguarding issues and therefore the amount of time required to undertake a comprehensive analysis.

Focussed inspections will not include structured conversations, i.e. they will miss out step 2 above, however, it is expected that the Review Panel Member will spend some time preparing the professionals involved for the workshop so that they have a sound understanding of systems methodology and come prepared to both be challenged and, perhaps more importantly, learn and improve their working practice.

All reviews will include meetings with communication officers, regardless of the scale, on the understanding that the cases are likely to draw media attention. Communication Officers will be informed at the start of the process with a meeting scheduled prior to publication. Additional meetings may be held if the case is attracting media attention.

Phase 3: Report Publication

The key steps in Phase 3 are the same for all reviews, that is:

approval by the SCRG and the NSCB Chair and confirmation of the publication date

sending the final report to the HOA and advising them of publication date and inviting them to a meeting under Phase 4

sharing the report with the professionals involved with the case sending the report to the National Panel taking the report to the NSCB publishing the report on the website for a minimum of 12 months drafting an action plan around the recommendations (see Phase 4, below adding the recommendations and actions to the Composite Action Plan (see

section 11, below)

Phase 3 will be completed within six months of commissioning the review to adhere to the guidance set out in Working Together 2013. The caveat to this is whether criminal proceedings are ongoing, in which case the SCR process will align to the legal processes.

Phase 4: Disseminating Learning

The report is not the end of the process. Rather it marks the end of the SCR and signifies the start of the wider learning. It is imperative that the workforce understands that reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice.

Phase 4 focuses on translating the findings from the SCR into programmes of action which lead to sustainable improvements for the NSCB and its partner organisations. The NSCB should oversee the process of agreeing with partners what action they need to take in light of the SCR findings. All SCRs will have recommendations and from these action plans will be devised around three key themes:


training and workforce development, including dissemination to the NSCB’s Workforce Development Group;

performance management, also linked to the work of the NSCB subgroups in terms of policy review and development; and, crucially

communication

In addition to publishing on the website, communication and dissemination activities will include:

aligning lessons learned to Best Practice days ensuring that Barnardo’s, NSCB’s commissioned training provider, uses the case

in training sessions targeted dissemination, either through single agency or around multi-agency

arrangements working with specific cohorts, such as children with disabilities cross referencing findings and recommendations with other review processes,

such as Domestic Homicide Reviews, and ensuring that messages are shared with the Boards that commission them.

undertaking surveys of frontline staff to confirm that reviews are shared and lessons learned within agencies

monitoring agencies responses and actions through follow up work under Section 11 self assessments as defined by the Children’s Act 2004.

Where themes emerge and the issues are deep rooted and/or difficult to tackle, such as identifying Child Sexual Abuse or cases of chronic neglect, consideration should be given to developing road shows and/or naming the issue as a priority for the NSCB.


10. Timeline Flow Charts

The timelines for conducting SCRs are extremely tight. HOAs need to be clear about the time and resource involved for their staff so that they can support the process and direct staff to prioritise their diaries wherever possible to engage in the process.

Where cases are in criminal proceedings, timelines may be delayed.

To enable this, the Business Manager will produce a detailed time plan and work closely with Review Panel Members to agree dates that are convenient to all at the start of the process, based on the activities identified in the charts below.

Key to flow charts:

Acronyms:

HOA Heads of AgenciesIR Independent ReviewerKPE Key Practice EpisodeMEO Monitoring & Evaluation OfficerQA Quality AssuranceRP Review PanelSCIE Social Care Institute for Excellence

Activity Type Colour Codes:

MAUVE Overview from SCRGPURPLE Overview from BoardGREY Admin tasksLIGHT BLUE Half day meetingsDARK BLUE Full day meetingLIGHT GREEN Half day workshopDARK GREEN Full day workshopPINK structured conversations/interviewsBLACK Writing timeRED Publication and/or media event/prep

NB. The Business Manager will factor in Board meeting dates in all planning to ensure that the report goes to Board prior to publication wherever possible. Should there be a significant timelag SCRG signing off on the report and the next Board meeting, the Business Manager will advise Board Members of Key Practice Episodes and any initial analysis of system failings.


FULL REVIEW TIMESCALE

Review Panel members will be asked to attend three half day meetings and four full day meetings in this process, including scoping and signing off on the report. They will also be required to attend one half day and one whole day workshop.

No. of working

days from approval

No. of Weeks Acitvity Type Activity Person(s) responsible

N/A 0 Overview SCRG decides case meets criteria for full scale review SCRG

N/A 0 Overview Chair notified of case & agrees Chair

N/A 0 Admin Business Manager notifies, Ofsted the DfE and submits SCR1 to National Panel. In conjunction with this tasks include:

Business Manager

(1) contact Lead Reviewers (advise National Panel on confirmation)(2) pencil in meeting dates & deadlines(3) draft letters to Heads of Agencies(4) Communication Officers advised

0 0 Overview National Panel acknowledges decision National Panel

1 1 Admin Heads of Agency notified: letters sent SCR Administrator

5 to 10 1 to 2 Meeting Scoping meeting with SCR Panel members (half day) IRs & RP

25 5 Admin Chronology compiled & circulated RP & SCR Admin

30 6 Meeting Meeting 1: confirm dates, case group and roles (half day) IRs & RP

35 7 WorkshopInitial workshop (half day): Staff intrdouced to systems methodology, rationale of conducting SCR and advised of next steps

IRs, RP & Case Group

PHAS

E 1:

SCO

PE &

PAR

AMET

ERS


45 9 InterviewsRP conduct 1-2-1s with Case Group Members and notes written up RP & Case Group

50 10 Meeting Meeting 2: Documents compiled and full day spent on identifying KPE. Gaps identified

IRs & RP

55 11 Interviews Outstanding interviews conducted, including conversation with family. Notes written up

IRs & Business Manager

60 12 Meeting Meeting 3: Follow up on meeting 2. Initial planning of professional workshop day

IRs & RP

70 14 Writing Time LR to produce and circulate KPE report to RP ahead of SCRG IRs

75 15 Meeting Meeting 4: (half day) LRs & RP agree KPE report to share with professionals

IRs & RP

80 17 WorkshopFull day workshop to share emerging analyses, review KPE report and contribute to recommendations IRs, RP & Case Group

85 18 OverviewKPE report taken to SCRG as update on process so far. Advise on how to prepare LSCB on predicted findings re systems

IRs & SCRG

90 19 Writing TimeLR to produce first draft of systems analysis report identifying underlying patterns and recommendations for publication; circulate to RP

IRs & RP

95 20 Meeting Meeting 5: LRs & RP agree report for publication and commence action planning to include:

IRs & RP

(1) presentation to Board(2) action plan around recommendations(3) incorporation of reccommendations into CAP(4) any learning material required to support dissemination

95 20 MeetingBusiness Manager to meet with Communication Officers from Heads of Agency to agree strategy for responding to media interest on publication

Business Manager & Communication Officers

110 22 Writing Time Final preparation of report for SCRG allowing time for comment from RP

IRs

110 22 QA LRs have findings clinic with SCIE IRs & SCIE

PHAS

E 2:

ANA

LYSI

S &

ENG

AGEM

ENT


110 22 Overview Final report to SCRG ahead of Board for questions and sign off LRs & SCRG

115 23 Writing Time Time allowed for any amendments/slippage to process ahead of Board

LRs & Business Manager

120 24 Meeting LRs & RP meet to agree final action plan to underpin recommendations. To be sent with report prior to publication

LRs & RP

120 24 Admin Report sent to Heads of Agency with date for action planning meeting

SCR Administrator

125 25 Overview Report to BoardSCRG Chair & Business Manager

125 25 Overview Head of Agency meet to discuss findings/recommendations and agree action plan

NSCB Chair & HOA

125 25 Admin report sent to RP to circulate to Case Group ahead of publication

RPs & Case Group

125 25 Admin Report shared with family Business Manager

125 25 Overview Report sent to National Panel of Experts Business Manager

130 26 PUBLICATION Report published on website Business Manager

Dissemination Report shared with any relevant Board or governing body Business Manager

Monitoring Recommendations added to CAP and RAGG rated NSCB Monitoring & Evaluation Officer

Training Report to NSCB Workforce Development Group & commissioned training provider

Business Manager

Dissemination Report presented to LSCGs Business Manager

Monitoring Progress on action plan reported to SCRG & HOA NSCB Monitoring & Evaluation Officer

Training Best Practice Day and/or Road Shows plannedNSCB Workforce Development Officer

Monitoring Progress on action plan reported to SCRG, HOA & Board NSCB Monitoring & Evaluation Officer

within four weeks

within six weeks

PHAS

E 3:

PUB

LICA

TIO

N

within eight weeks

within 3 months

within 6 months

within 12 months

PHAS

E 4:

DIS

SEM

INAT

ION

within one week


MEDIUM REVIEW

Medium scale reviews will be commissioned for cases that:

have features of a full review, but the degree of serious harm or long term impairment cannot be ascertained at the point of commissioning the review


The timeline for the medium review will therefore fall somewhere between a full scale review and a focussed review. In terms of project planning, the Business Manager will work with the full scale review timetable in the first instance. The steps we anticipate missing out are:

Phase 1: Scope & Parameters The workshop in week 7 is likely to be omitted. The Review Panel will be issued with guidance packs for the Case Group ahead of their structured conversations

Phase 2: Analysis & Engagement The Business Manager will work with the Lead Reviewer and Review Panel to assess the number of meetings required at scoping and review again after the chronology is compiled.

As a minimum, it is expected that Meeting 2 in Week 10 and Meeting 5 in Week 20 will be half day

Phase 3: Publication No Changes

Phase 4: Dissemination No Changes


FOCUSED REVIEW

Focussed reviews are the least resource intensive of the options. The Review Panel are required for three half day meetings plus the scoping meeting and a half day workshop with the Case Group.

In terms of scoping, if a focussed review is commissioned the SCRG will be able to provide the time parameters based on the referral information. The scoping meeting in Phase 1 is unlikely to take a full half day, but will be an opportunity to both ensure that the Review Panel is confident with the process as well as confirm the Case Group.

No. of working

days from approval

No. of Weeks Acitvity Type Activity Person(s) responsible

N/A 0 Overview SCRG decides case meets criteria for full scale review SCRG

N/A 0 Overview Chair notified of case & agrees Chair

N/A 0 AdminBusiness Manager notifies, Ofsted the DfE and submits SCR1 to National Panel. In conjunction with this tasks include: Business Manager

(1) contact Lead Reviewers (advise National Panel on confirmation)(2) pencil in meeting dates & deadlines(3) draft letters to Heads of Agencies(4) Communication Officers advised

0 0 Overview National Panel acknowledges decision National Panel

1 1 Admin Heads of Agency notified: letters sent SCR Administrator

5 to 10 1 to 2 Meeting Scoping meeting with SCR Panel members (half day) IR & RP

25 5 Admin Chronology compiled & circulated RP & SCR Admin

PHAS

E 1:

SCO

PE &

PAR

AMET

ERS


30 6 MeetingMeeting 1: review chronology and bullet point KPEs identified in preparation for Case Group meeting/workshop. RP & Case Group

50 10 Workshop Case Group meeting (half day) to share emerging analyses, review KPE report and contribute to recommendations

IR & RP

60 12 Writing TimeLR to produce first draft of systems analysis report identifying underlying patterns and recommendations for publication; circulate to RP

IR

65 13 Meeting Meeting 2 (half day): LRs & RP agree report for publication and commence action planning to include:

IR & RP

(1) presentation to Board(2) action plan around recommendations(3) incorporation of reccommendations into CAP(4) any learning material required to support dissemination

65 13 MeetingBusiness Manager to meet with Communication Officers from Heads of Agency to agree strategy for responding to media interest on publication

Business Manager & Communication Officers

65 13 QA LRs have findings clinic with SCIE IR & SCIE

PHAS

E 2:

ANA

LYSI

S &

ENG

AGEM

ENT


110 22 Overview Final report to SCRG ahead of Board for questions and sign off IRs & SCRG

115 23 Writing Time Time allowed for any amendments/slippage to process ahead of Board

IRs & Business Manager

120 24 Meeting LRs & RP meet to agree final action plan to underpin recommendations. To be sent with report prior to publication

IRs & RP

120 24 Admin Report sent to Heads of Agency with date for action planning meeting

SCR Administrator

125 25 Overview Report to BoardIRs, SCRG Chair & Business Manager

125 25 Overview Head of Agency meet to discuss findings/recommendations and agree action plan

NSCB Chair & HOA

125 25 Admin report sent to RP to circulate to Case Group ahead of publication

RP & Case Group

125 25 Admin Report shared with family Business Manager

125 25 Overview Report sent to National Panel of Experts Business Manager

130 26 PUBLICATION Report published on website Business Manager

Dissemination Report shared with any relevant Board or governing body Business Manager

Monitoring Recommendations added to CAP and RAGG rated NSCB Monitoring & Evaluation Officer

TrainingReport to NSCB Workforce Development Group & commissioned training provider Business Manager

Dissemination Report presented to LSCGs Business Manager

Monitoring Progress on action plan reported to SCRG & HOANSCB Monitoring & Evaluation Officer

Training Best Practice Day and/or Road Shows planned NSCB Workforce Development Officer

Monitoring Progress on action plan reported to SCRG, HOA & Board NSCB Monitoring & Evaluation Officer

within six weeks

PHAS

E 3:

PUB

LICA

TIO

NPH

ASE

4: D

ISSE

MIN

ATIO

N

within 12 months

within eight weeks

within 3 months

within 6 months

within one week

within four weeks


11. Composite Action Plan

The NSCB is committed to demonstrating that lessons from SCRs have been learned and improvement is sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children. One of the tools we use to do this is the Composite Action Plan (CAP) which incorporates the recommendations from all the reviews undertaken since 2006.

The CAP categorises the recommendations so they can be analysed by theme and/or by agency. Progress against these actions is RAGG rated, that is assessed as Red, Amber, Green or Grey – grey depicting that the action has been fully implemented and the risk of a subsequent system failure is negligible.

The NSCB’s Monitoring & Evaluation Officer (MEO) is responsible for tracking progress on the CAP recommendations and aligns them to the Section 11 self assessment processes where appropriate.

The CAP is reviewed three times annually by the SCRG and the MEO to agree the progress of the actions. RAGGs rated as grey can be archived.

SCR meetings to consider the CAP from 2013 are scheduled in:

July November March

In addition, the CAP is measured and monitored as part of the wider NSCB dataset and is a key aspect of the Performance Framework.

12. National Panel of Experts

On 6 June 2013, Education Secretary Michael Gove announced that a new national panel of independent experts had been established to help ensure that lessons are learned when a child dies or is seriously harmed and there are signs of abuse or neglect. This National Panel oversees the SCR process, advising and challenging LSCB Chairs on whether or not to initiate an SCR, whether to appoint certain reviewers, and whether to publish SCR reports.

The National Panel members are experts in their field and will bring much needed independent, rigorous scrutiny to the system - advising, supporting and challenging LSCBs to do better at completing and publishing SCRs. The National Panel includes professionals from:

National Society for the Prevention of Cruelty to Children (NSPCC): Peter Wanless became Chief Executive of the NSPCC on 3 June. He joins NSPCC from the Big Lottery Fund where he was Chief Executive for 5 years, responsible for distributing £750 million a year across the UK to projects and programmes designed to benefit communities and people most in need. Peter was previously a director at the Department for Education, specialising in schools’ reform.

Air Accidents Investigation Branch (AAIB): Nicholas Dann is Head of International Development at the AAIB, the government body charged with the investigation of accidents and serious incidents to aircraft. He has over 10 years’


experience as a senior inspector of air accidents during which time he has investigated a wide range of accidents, both in the UK and overseas.

Family Law: Elizabeth Clarke is a practising barrister who has specialised in family law for over 20 years, having been called to the Bar in October 1991.

Media: Jenni Russell is a columnist for the Sunday Times, the Evening Standard and the Guardian. She worked as a broadcaster for many years, at Channel 4 News and at the BBC, where she was the editor of The World Tonight on Radio 4. She won the Orwell Prize for political journalism in 2011.

These are public appointments. The panel became operational on 1 July 2013

Working Together 2013 clearly states that “the final decision to conduct the SCR rests with the LSCB Chair”. If the LSCB decides not to initiate a serious case review, the Chair may be required to attend the national panel to explain their decision. The panel cannot take enforcement action. Its role will be an advisory one, however, the government expects LSCBs to have due regard to its advice.”

The instructions issued by the National Panel from 1 July 2013 are attached as Appendix 9.


Appendix 1: Munro’s paper on a Systems Approach

What is a systems approach?Eileen MunroFebruary 2012

This paper clarifies what I meant by recommending that the Government adopts a systems approach for undertaking Serious Case Reviews. It draws on discussions I have had with colleagues working on error investigation in health, child protection, and aviation.

The crux of a systems approach as developed in health, aviation, and engineering is that it examines human performance in its context and recognises that people’s competence in carrying out tasks to a high standard is influenced by the whole system around them. The work environment has of course been designed with the aim of making that influence constructive but a systems investigation or review examines how well this has been achieved. Around 75% of major enquiries, whether in child protection, health, or aviation, conclude that the outcome was due to human error. Prior to the development of a systems approach, this conclusion was seen as a satisfactory explanation and solutions generally focused on the people who made the error. In a systems review, however, the finding of human error is the start of an enquiry.

Lord Laming concluded his enquiry into the death of Victoria Climbie with thecomment:

Even after listening to all the evidence, I remain amazed that nobody in any of the key agencies had the presence of mind to follow what are relatively straightforward procedures on how to respond to a child about whom there is a concern of deliberate harm (2003 para. 1.19)

It is this ‘amazement’ that a systems enquiry aims to remove: what information was reaching the professionals; how did they (mis) interpret it? Why did safety mechanisms such as supervision not function?

An early example from aviation is Fitts and Jones (1947) study of World War Two airplane cockpits showing how the poor design of the flap and landing-gear handles (similar shape and located side-by side) made it easy to confuse them and this was particularly likely to happen when coming into land when pilots were handling several tasks at the same time. In the typical accident, a pilot would raise the landing gear instead of the flaps after landing, damaging the propellers, engines and air-frame. Re-designing the handles reduced the error rate.

The goal of systems investigations is to build up understanding of how errors are made more or less likely depending on the factors in the task environment. This allows innovations that maximise the factors that contribute to good performance and minimise the factors that contribute to error. In re-designing the system at all levels to make it safer, the aim is ‘to make it harder for people to do something wrong and easier for them to do it right’ (Institute of Medicine, 1999 p.2)


How prescriptive to be(a) prescribing essential criteria of an investigation

What ingredients must be present to justify the name a ‘systems approach’? First, a focus on the person in context, seeing performance as arising from the interaction of the context and what the individual brings to it. This contrasts with current SCRs where typically performance is judged relative to an ideal model based on compliance with procedures and guidance, and recommendations take the form of adding procedures (Rose & Barnes, 2008).

Secondly, the aim of understanding why someone acted as they did, not just describing what they did. Again, current SCRs are poor at this; Ofsted critically noted that ‘SCRs were generally successful at identifying what had happened to the children concerned, but were less effective at addressing why’ (OFSTED, 2008). In a systems approach, the aim is to avoid the hindsight bias that grossly distorts our retrospective analysis of a case and seek to understand how things were perceived and the rationale for decisions, actions, or inactions at the time.

Thirdly, the aim of finding underlying patterns that indicate recurring latent weaknesses in the system that can contribute to poor performance, i.e. the individual case is taken as ‘a window on the system’ (Vincent, ) This enables the enquiry to extrapolate from the individual instance to general lessons. For example, in a particular case, problems were caused because health staff would write back to the GP, as the original referrer, and just copy social workers in, not address them directly.

However they included in the letter actions they wanted the social worker to do. Social workers, seeing they were copied in to the letter, assumed it was just for information, and filed it, without even reading the content, so overlooking the request for action. Reviewers needed to find out if whether this was just a one off occurrence or not. Discussions with staff revealed that the mismatch of expectations was not restricted to these particular staff, but were accepted cultural norms within the respective professional groupings. Hence the inconsistent use of the ‘cc’ function was identified as a generic, underlying pattern that created the condition for predictable errors in communication. Given the high level of traffic in these kinds of letters, the prevalence was also high..A fourth component is the use of research methods to maximise the reliability and validity of the findings. This of course is relevant whatever approach is being used but the current system for SCRs does not require those conducting them to have any training in methods nor are there quality assurance processes to focus on them. A requirement that at least one person involved in conducting an SCR has training would be desirable not only in terms of research methods but also because experience in other fields (e.g. National Patient Safety Agency) has found that reading a textbook or attending a lecture is insufficient for achieving the paradigm shift from a person centred to systems-centred focus.


Beyond these assumptions, it is possible to investigate performance in a number of ways. The ‘Learning Together to Safeguard Children’ model (S Fish, E Munro, & S Bairstow, 2008) has been developed specifically for child protection cases. There are similar models in other fields that could be adapted, e.g. the London model developed by Charles Vincent.(2006) for use in the health sector. Beyond incident investigations or case reviews, there are also a number of alternative methods that target specific parts of the problem, e.g. human factors studies of situational awareness, or technology studies of human-computer interactions.

(b) prescribing a categorisation scheme for presenting findings to facilitate national learning

For national learning to be possible, it is desirable to prescribe some uniformity in how findings are organised, i.e. a typology of error causation. In the work I did with SCIE, we took the common features of such typologies that had been developed in other areas of work and then modified them to suit child protection. The following typology was developed:

1. Human biases (cognitive and emotional): Are there common errors of human reasoning and judgement that are not being picked up through current case management processes?

2. Family-professional interaction: What patterns are discernable in the ways that professionals are interacting with different family members, and how do they help and or hinder good quality work?

3. Responses to incidents: Are there particular good or bad aspects to the patterns of how professionals respond to specific incidents (e.g. allegations of abuse)?

4. Longer term work: Were any good or bad patterns identified about ways of working over a longer period with children and families?

5. Tools: What has been learnt about the tools and their use by professionals?

6. Management system: These particular form lines of enquiry to be used when considering what has been learnt from the single case about generic, underlying patterns, in the last stage of the review:

Are any elements of management systems a routine cause for concern in any particular ways?

The background to this scheme is available in the original report (Sheila Fish, Eileen Munro, & Sue Bairstow, 2008).

The Voluntary and Community Sector grant that DfE awarded SCIE includes further work on developing this typology further to include sub-categories, based on the sample of Learning Together reviews as they increase. The grant also funds SCIE to collate findings of multiple case reviews in a timely fashion using this typology and to make them publically available. These developments are currently underway.


I would suggest that there is merit in prescribing this level of structure to report findings so that it is possible to share and collate findings at a national level. Over time, the typology could become more and more detailed.

Understanding why things went wrong and improving performance

There are two separate stages to improving performance. First, there is the enquiry to understand what happened and, if appropriate, why there were flaws in the performance (some child deaths could not have been predicted or prevented by even the highest level of professional practice) and the underlying patterns this reveals.

The second stage is to consider whether those patterns should be addressed, and what the right way of achieving change might be so as to create a situation more conducive to good quality work.

A systems approach to investigations helps us understand why things went wrong in this particular case and whether it is a potentially recurring issue. This does not in itself tell us how to improve performance. Just as an MRI scan can tell doctors there is a brain tumour but does not tell them how to perform the operation safely, a systems report identifies the areas of weakness in practice that need to be altered to reduce the chances of error.

Systems investigations highlight a range of types of problems. These vary along a spectrum from problems with knowable solutions to ‘puzzles’ that can never be truly resolved. While it is helpful to construct SMART recommendations for the former, the latter often entail relative risks and competing priorities, that those in strategic positions of responsibility need to consider carefully in light of their overall responsibilities.

So if a case review highlights that a recent domestic violence strategy, while dealing very well with the ‘high end’ urgent cases involving domestic violence, leaves the larger number of important but not urgent ones without response, then this is not a problem to which there is a straightforward remedy yet it is nonetheless important to tackle. Recent research (Brandon & Sidebtoham ) has highlighted how the current focus on SMART recommendations has inadvertently led to LSCBs focusing only on the easily attainable and avoiding the difficult but arguably more crucial issues

Such recommendations do not meet the current Ofsted evaluation criterion where an outstanding recommendation meets the standard: ‘areas for changes in practice are clearly identified and supported with measurable and specific recommendations for improvement’. This seems to me to seriously underestimate the complexity of practice and the challenges we face in seeking to improve performance.

Department of Health. (2003). The Victoria Climbie Inquiry. London: Department of Health.


Fish, S., Munro, E., & Bairstow, S. (2008). Learning Together to Safeguard Children. London: SCIE. Fish, S., Munro, E., & Bairstow, S. (2008). Learning together to safeguard children. Developing a multi-agency approach for case reviews. SCIE Report 19. London: Social Care Institute for Excellence.Fitts, P., & Jones, R. (1947). Analysis of factors contributing to 460 'pilot error' experiences in operating aircraft controls. Ohio: Aero Medical Laboratory. Institute of Medicine. (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academic Press.OFSTED. (2008). Annual Report of Her Majesty's Chief Inspector of Education, Children's Services and Skills 2007/08. London: DCSF.Rose, W., & Barnes, J. (2008). Improving safeguarding practice: study of serious case reviews 2001-2003. London: Department of Children, Schools and Families.Vincent, C. (2006). Patient Safety. Edinburgh: Elsevier.


Appendix 2

Serious Case Review Referral Form: SCR 1

DEATH OR SERIOUS INJURY TO A CHILD WHERE A CHILD PROTECTION ISSUE IS LIKELY TO BE OF MAJOR PUBLIC CONCERN

THIS DOCUMENT WILL ONLY BE CONSIDERED BY THE SERIOUS CASE REVIEW GROUP WHEN ONE OR MORE AGENCY HAS CONTRIBUTED TO THE REFERRAL.

ALL INFORMATION PROVIDED SHOULD ADHERE TO WORKING TOGETHER GUIDANCE 2013 WITH REFERENCE TO THE CRITERIA STATED UNDER REG 5 OF THE LSCB REGULATIONS

1.) Notifier’s Details

N.B: The information provided by the notifier should be supported by additional information from at least one partner agency and clearly relate to the criteria for undertaking a serious case review, i.e.:

known or suspected abuse/neglect the death of a child serious harm to a child linked to concerns about agencies working together

Date of Notification:Notifier’s Name: Notifier’s Role: Notifying Agency(CPC1 Lead):Notifier’s Telephone:Agencies involved in notification process – please tickPolice Children’s

Social CareCDOP Other:

(Please specify below)Health Education CAFCASS

2.) Child‘s Details

Child's Last Name:Child's Forename(s): Parent Names:Siblings’ Names (with DOB):Date of Birth of child: Age of child:Gender: (MALE/FEMALE) Ethnicity:Name of School (s)/ EY ProvisionHousing Association (if relevant)Child Protection Plan: Was a child protection plan in place at the time of the incident? (YES/NO):


CPP: If yes, please provide details below, including date of the plan:

Legal Status of the child:

What was the legal status of the child at the time of the incident – please tick:

Emergency Protection Order: Ward of Court: Police Protection: Section 20 Accommodation; Supervision Order: Other/None (Please specify below)Interim Care OrderCare Order:Please provide date and details of order/protection arrangements:

3.) Incident Leading to the Referral

Date of Incident: Date of Death of the child (if relevant):Residence of the child (at time of Incident): Details of the Incident: (including where the incident took place)NOTIFYING AGENCY INFORMATION

Background information & record checks to support referralThis information needs to relate to the criteria for undertaking a review – See (4) below.Please provide as much detail as possible – there is no word limit: boxes expand.

1.) POLICE

2.) HEALTH

3.) CHILDREN’S SOCIAL CARE4.) EDUCATION

5.) OTHER


4.) Does this case meet the criteria to conduct a Serious Case Review

Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. and 5 (2) For the purposes of paragraph (1) (e), for this case to meet the threshold for conducting a serious case review, you must indicate whether:

SERIOUS CASE REVIEW CRITERIA YES/NO

5 (2) (a) abuse or neglect of a child is known or suspected:

5 (2) (b) (i) the child has died NB: this includes cases where a child or young person died in custody, police custody on remand or following sentence in a Young Offender Institution, in a secure training centre or secure

children’s home where the child was detained under the Mental Health Act 2005 a child died by suspected suicide

5 (2) (b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

Abuse or Neglect: YES/NOHas the child/young person sustained a potentially life-threatening injury?Is it possible to establish whether the child or young person is likely, i.e. on the balance of probability, to suffer serious and permanent impairment of physical and/or mental health and development through abuse or neglect?Please identify the type(s) of abuse relating to this case below.

Physical Abuse Sexual AbuseEmotional Abuse Sexual ExploitationNeglect OtherPlease use the space below to provide any further information to support the decision to commission a review

Please provide enough information to enable the SCRG to assess whether the grounds have been met i.e. in what way the death/serious harm is related to abuse/neglect and, in relation to Regulation 5(2)(b)(ii), the nature of the serious harm and the nature of the concerns about working together to safeguard children. .

If you answered yes to 5 (2) (a) and 5 (2) b above, this is a serious case review. If no, would the case be suitable for:


TYPE OF REVIEW YES/NOMulti-Agency Review – involving two or more partnersSingle Agency Review – involving an internal management review

Please provide details below of why this case requires a different type of review

5.) Criminal Proceedings

Are there criminal proceedings? (YES/NO)If so, what is/are the anticipated date(s) of trial:

6.) Decision-making record (for SCRG only)

Date CPC1 receivedDate presented to SCRG

ACTION LOGDATE Actions agreed at SCRG

Type of review agreed: Please specify or indicate NFA

7.) For Office Purposes only

Date review commissioned & NSCB Chair Notified:Date NSCB Chair signs off on Serious Case ReviewDate Ofsted and the DfE notifiedDate SCR1 submitted to National Panel:Date Heads of Agencies notified:Date Reviewer(s) appointed:Name of Reviewer(s):Publication Date:


Appendix 3: Template Letter to Heads of Agency at start of SCR

NameTitleAddress 1Address 2TownPostcode

Date

Dear Name of HOA,

Re: Serious Case Review, Name of Child [dob 23.05.11]

The Serious Cases Review Group (SCRG) of Norfolk SCB met on Monday Day Month Year, and considered this case which concerns brief summary of case. Further detail is provided in the enclosed SCR1.

The SCRG decided that the criteria for undertaking a serious case review under Chapter 4 of Working Together 2013 were satisfied and I have agreed that the review should proceed. The National Panel has been notified. The Serious Case Review will be project managed by the NSCB Board Manager Abigail McGarry.

The SCRG have decided that this case should be conducted as a full/medium focused review. The procedure guidance is attached for your reference.

An initial scoping meeting has been arranged for Date and time of scoping meeting Please can you:

identify a representative from your agency to be part of the Serious Case Review Panel and advise them of the date of the scoping meeting.

confirm with Abigail who the representative is and she will contact them with details of the scoping meeting and review process, including the support they can expect from the NSCB.

The timeline for the review includes Number of Panel meetings and a professional learning workshop day where all frontline staff involved in the case will have an opportunity to review the chronology and contribute to the findings and recommendations.

The draft SCR report is due to be signed off by the SCRG on Monday Day Month Year, and you will be sent a copy of the final report prior to publication and

SCR Processes & Guidance

Norfolk Safeguarding Children Board

Room 60, County Hall, Martineau LaneNORWICH NR1 2DHTel (01603) 223409

email: [email protected]

37

presentation to Board on Day Month Year. Please can you allow time following the Board meeting to review the recommendations with partner agencies involved in the case and consider the proposed action plan to address issues identified and disseminate learning. We will send out an invitation to this meeting closer to the time.

If you have any questions about this process, please contact Abigail on 01603 223335. We will keep you informed of the progress of the review.

Yours sincerely

David AshcroftIndependent Chair, Norfolk SCB

Enclosures: SCR1 Proposed timeline Serious Case Review Procedures

CC Name of SCRG Member, Name of Agency member of SCRG


Appendix 4: Heads of Agencies and Members ListSCR CONTACTName, Title & Address e-mail & Phone

NSCB Member (to be copied in if different from SCR contact)

SCRG Member (if applicable)

Copy in Panel MembersAlso consider copying in:

CHILDREN’S SERVICESSheila LockInterim Director of Children's ServicesCounty HallMartineau LaneNorwich, NR1 2DH

NB Check with NSCB Chair re sending report to Norfolk County Council CEX

[email protected] 222601 - 07787 711288

N/A Wendy Dyde, Independent Chairing Manager

Panel Members for CSC, e.g.: Andrea Brown Jackie Cole

Panel Members for Edu, e.g.: Kelly Waters

Consider cc’ing to AD for Education if applicable

Harold BodmerDirector of Community ServicesCounty HallMartineau LaneNorwich, NR1 2DH

[email protected] 223175

[email protected] 223960 - 07876 577361

Debbie OlleyAD: Integrated. Community Services, (Adult Social Care)

N/A

Consider cc’ing Linda Naylor, Adults Safeguarding Board Manager

AGENCIES WITH LINKS TO THE CRIMINAL JUSTICE SYSTEM

Chris Small Head of Norfolk Youth Offending TeamCounty HallMartineau LaneNorwich, NR1 2DH

[email protected] – 07899 862672

N/A

Nick DeanTemporary Assistant Chief ConstableJubilee HouseFalconers ChaseWymondhamNorfolk, NR18 0WW

[email protected]

[email protected] 424875 – 07770 [email protected] 276001 - 07799 616774

Jo ShinerChief Superintendent

Julie WvendthDetective Superintendent

NB Check with JW re SCR contact each time

Panel Member - from Jun 2013: this will probably be Ross McDermott.

Mr Martin GrahamCEO Norfolk & Suffolk Probation TrustNorwich Probation OfficeCentenary House, 19 Palace StreetNorwich, NR3 1RT

[email protected] 282340 or 01603 302245 Sarah Wardley

SCRG Chair


mailto:[email protected]









SCR CONTACTName, Title & Address e-mail & Phone




HEALTH COLLEAGUES: CCG & Community HealthcareMs Catherine GormanDirector Quality and SafetyNHS Great Yarmouth and Waveney CCGBeccles House1 Common Lane NorthBecclesSuffolk NR34 9BN

[email protected]

Mobile: 07786 551646Tel: 01502 719561 N/A

Jane BlackDesignated Nurse

Sue ZeitlinDesignated Doctor

Advise which providers have been involved, e.g. ‘We are writing separately to…’

Panel Members for Health Either Jane or Mark Gower

Mr Michael ScottChief Executive, NCHCElliott HouseBer StreetNorwich, NorfolkNR1 3FR

[email protected]


Anna MorganDirector of Nursing N/A

Advise you have written to the CCG Lead separately

Panel Members for NCHC, e.g. Anne Pringle

Jonathan Williams Director of Quality & AssuranceEast Coast Community Healthcare CICBeccles House1 Common Lane NorthBecclesSuffolk NR34 9BN


N/A N/A


Named nurse: Ali Jennings

[email protected] 527581 – 07771 623950






SCR ContactName, Title & Address e-mail & Phone




HEALTH COLLEAGUES: Acutes, Foundation Trust (Mental Health) & AmbulancesMrs Wendy SlaneyChief ExecutiveJames Paget University HospitalLowestoft Rd Gorleston-on-Sea Great Yarmouth, Norfolk NR31 6LA

[email protected]


Elizabeth LibiszewkiDirector of Nursing, Quality and Patient Experience N/A


Named Nurse: Patricia Hagan

[email protected] 453964 – 07880 500198

Anna DugdaleChief ExecutiveNorfolk & Norwich NHS Foundation TrustColney LaneNorwichNR4 7UY

[email protected] 287479 - 07824 707469 Emma McKay

Director of Nursing N/A


Patricia WrightChief ExecutiveQueen Elizabeth HospitalGayton RoadKing’s LynnNorfolkPE30 4ET

[email protected]

[email protected]

[email protected] 613613 ext 3582

Gwyneth WilsonDirector Patient Experience and lead for Nursing and non-medical professionals

Valerie NewtonPractice Development Nurse

N/A


Aidan Thomas Chief ExecutiveNorfolk and Suffolk NHS Foundation Trust Hellesdon HospitalDrayton High RoadNorwichNR6 5BE

[email protected]

[email protected] 421660 – 07799 895185

Jane Sayer Director of Nursing, Quality & Patient Safety N/A


Consider cc’ing Saranna Burgess, Named Nurse for Safeguarding Children and Adults

Dr Scott TurnerAssociate DirectorEast Of England Ambulance Service NHS TrustNorwich OfficeAmbulance StationHospital LaneNorwich, NR6 5NA


[email protected] 712434 – 07917 657192

Anneliese Hilyer-Thake N/A




















District CouncilsTrevor HoldenInterim Chief Executive Breckland CouncilBreckland CouncilElizabeth House, Walpole LokeDereham, NR19 1EE

[email protected] 01362 656300 – 07823 553988 Riana Rudland (rep)

Community Development Manager

N/A

Phil Kirby Chief Executive Broadland District CouncilBroadland District CouncilThorpe Lodge1 Yarmouth Road Thorpe St AndrewNorwich, NR7 0DU


Richard Block (rep)Head of Housing and Environmental Services

N/A

Laura McGillivrayChief Executive Norwich City CouncilNorwich City CouncilCity HallSt Peter’s StreetNorwich, NR2 1NH

[email protected]


Bob Cronk (rep)Head of Community Services

N/A

Jane RatcliffeChief ExecutiveGreat Yarmouth Borough CouncilTown Hall, Hall PlainGreat YarmouthNorfolk, NR30 2QF

[email protected] 846301 – 07920 843289 Robert Read (rep)

Director of Housing and Neighbourhoods

Sheila Oxtoby (CEX) Chief Executive North Norfolk District CouncilCouncil OfficesHolt Road, CromerNorfolk, NR27 9EN

[email protected]

[email protected] 01263 516173

Sonia Shuter (rep)Health Improvement Officer

N/A
















District CouncilsSandra Dinneen Chief Executive South Norfolk District CouncilSouth Norfolk HouseSwan Lane, Long StrattonNorfolk, NR15 2XE

[email protected] 01508 533718

Mike Pursehouse (rep)Communitites Manager

Ray HardingChief Executive Kings Lynn & West Norfolk District CouncilKings Court, Chapel StreetKing’s LynnNorfolk, NR30 1EX

[email protected] 616245 - 07776 467633


Debbie Gates (rep)Executive Director







Appendix 5: Template Letter to Professionals

Letter to professionals involved in the case of Child X

Dear colleague,

Name of Child, DOB

Someone from your team or organisation may have spoken to you about the plan to conduct a Serious Case Review (SCR) of the case of Child X; this has been commissioned by Norfolk Safeguarding Children Board. We are sending you this letter in order to give a brief summary of the approach that is going to be taken and the role that we would like you to play, as one of the professionals involved with the child/family.

The approach

In this case review we are going to use a new method called ‘systems analysis’. Until recently, this sort of review process would have been familiar to Health colleagues, but perhaps less so to the wider safeguarding network.

A systems approach concentrates not on judging individual people’s work. Instead, by taking account of the situation they were in, the tasks they were performing, and the tools they were using etc, it focuses on understanding why someone acted in a certain way. It highlights what factors in the system contributed to their actions making sense to them at the time. Importantly, it also highlights what is working well and patterns of good practice.

The review serves as a means of finding out how well local safeguarding systems are operating, more widely, thus ensuring that there is wider learning which will be relevant to current and future work.

The systems approach adheres to the Working Together guidance published in 2013. For more information see Chapter 4, link below, or contact the NSCB Business Manager on 01603 223335.

https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-00030-2013

Your role in the SCR

The SCR Panel is comprised of senior members of the agencies who were involved in the family of Child K, and is led by an Independent Reviewer, Name of Reviewer. Your agency representative on the SCR Panel is Name of Panel Member. They will be in touch with you to begin the process of ensuring the records from this case are included in a multi-agency chronology and arrange an individual interview with you. This will either be carried out by


Norfolk Safeguarding Children BoardRoom 60, County Halll, Martineau Lane,

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your agency representative, or another Panel member, and a minute-taker will also be present.

Secondly, we are planning a Workshop Day when all the professionals involved in the case will be invited to come together and discuss the case – based on the preliminary analysis of the Panel. The learning from the case review is significantly strengthened by the involvement of the front-line professionals (and first-line managers), who are able to talk about their work in a way that does not get fully reflected in case records/chronologies.

The Workshop Day is currently planned to be on XXXXXXX. – venue to be confirmed. Please can you ensure that this date is in your diary. The day will begin with a short presentation about the systems model which underpins this case review. The systems approach relies very much on the participation of the professionals (front-line workers and their supervisors) involved in a case, who can help us understand why things happened as they did, what was influencing the decisions made and the nature of the work, etc.

During the workshop you will be asked to spend some time reading the case chronology and considering the key practice episodes (KPEs). The KPEs will set out the Panel’s preliminary analysis and the themes of the review to date, and will also include questions which we need your help with. For most of the rest of the day, we will work in small groups: to get your response to the report, and to continue a discussion of the material. You will have a chance to question the analysis and to add any points of your own which we have missed. Our expectation is that your input to the analysis will make the findings of the review richer, more valid and more useful.

We also enclose some background information on the systems methodology written by Professor Eileen Munro.

If you have any questions about this process, please contact your agency representative.

We look forward to meeting with you soon.

Kind regards,

David AshcroftIndependent Chair, Norfolk SCB


Appendix 6: Conversation Structure Summary

Taken from SCIE’s guidance for conversations in Learning Together systems case reviews

1. Introduction

Purpose of the conversation Confidentiality and ethics Outline of the structure

2. Overview

Ask the professional to describe their role in the agency, and then to talk about this case – anything they would like to describe (allow them to choose what to tell you, and do not interrupt with prompting or clarifying questions during their response – you can make notes of what you would like to check out afterwards): what happened, how they responded, etc.

3a. ‘Turning points’ or ‘key practice episodes’

What do you think were crucial moments in this sequence, when key decisions or actions were taken that you think determined the direction the case took or the way the case was handled?

3b. ‘Mindset’ and ‘local rationality’

The professional may have covered some of the list below in his/her ‘Overview’ response. If not, you may want to prompt them with any of the questions below.

What did you think was going on here? What was behind your thinking (reasons but also emotions) and actions at the time? What information was at the front of your mind? What was most significant to you at

this point? What was catching your attention? What other things were occupying you at the time? What were your main concerns? What were you tossing up at the time? Did these

concerns clash at all? Were there any conflicts? Were some dismissed, others prioritised?

What were you hoping to achieve? What options did you think you had to influence the course of events? 4. Contributory factors

What were the key factors that influenced how you interpreted the situation and how you acted at the time? In what ways? Prioritise aspects that were most significant.

Aspects of the family Aspects of your role Conditions of work/work environment Personal aspects Your own team factors Inter-agency/inter-professional team factors Organisational culture and management Wider political context


Other

5. Things that went well

What things relating to the case went well? What do you think you or others did that was helpful/useful? And what factors

supported/enabled it?

6. Queries from the overview perspective

(These are questions which may have arisen from other “conversations” already undertaken with individuals from the same agency, or other agencies).

7. Suggested changes

Off the top of your head, having thought back on this case and your role, are there are any small, practical changes that you can think of, that would help you/staff do a better job?

8. Summing up

Read out your write-up of the conversation, in order to check: Have we got your view of the case?

9. Reflections How have you found this session? Do you have any comments or questions? How do you feel now, about yourself and your role, after this discussion?


Appendix 7: Template Letter to Parents/Carers

Name of Father/MotherAddress 1Address 2TownPostcode

Today’s date

Dear XXXXX,

Norfolk Serious Case Review

I am writing to tell you about a review which is being carried out regarding the work of agencies involved with your family. This is the responsibility of the Local Safeguarding Children Board in Norfolk.

Where a child has died or when serious harm comes to a child, this Board is required to review the work they have done with the family.

The aim of the review is to try to find out why things happened as they did, so that services can be improved where possible. This includes talking to the family to find out if,

there were any services which might have been of help to you and your partner?

local agencies were readily accessible, and was it clear what kind of help they had to offer?

We would be very grateful if you would be willing to talk to us about your experiences in this respect, and any views you might have. If you are willing to do so, we would arrange for the Independent Chair of the review to visit you for this purpose.

There is one other request, which is to ask whether you would allow the Health representative on the review panel to contact your GP and have access to your health records. The purpose of this would be to clarify your health needs, and whether these were understood by those working with you and your children

At the end of the review a report will be published on the Norfolk Safeguarding Children Board website and posted there for a minimum of 12 months. Reviews are follow the national guidance published in Working Together (2013), states that SCR


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NORWICH NR1 2DHTel (01603) 223409

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reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case. Reports are written in such a way that identities are protected.

If you have any questions about the process please do not hesitate to contact me.

We hope to hear from you soon.

Yours sincerely,

Abigail McGarryNorfolk Safeguarding Children Board Manager01603 223335


Appendix 8: Medical Consent Agreement

Safeguarding Children – Designated TeamLakeside 400 Old Chapel Way

Broadland Business Park Thorpe St AndrewNorwich

NR7 0WG

Tel: 01603 257164Fax: 01603 257295

[email protected]

RE: CONSENT FOR RELEASE OF INFORMATION

I, Name of Parent

DOB XXXXXX

NHS No. XXXXXX

hereby give my consent for the release of all my medical records to:

Name of requesting Agency Norfolk Safeguarding Children BoardDesignated Safeguarding Children Team, NHS Norfolk & Waveny

For the purpose of : Completion of Serious Case Review

Signed ………………………………………………….

(Print Name) ……………………………………………

Date …………………………………………………………..

