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Serious Case Reviews

SCOPE OF THIS CHAPTER

This chapter covers the requirements within Chapter 4 of Working Together to Safeguard Children 2015, which describes the way in which Serious Case Reviews should be initiated and scoped, and the principles that should be used when undertaking Serious Case Reviews, as well as other forms of reviews and audits.

Please note - Under the Children and Social Work Act 2017, Serious Case Reviews will be replaced by new national and local arrangements for reviewing serious cases. LSCBs must continue to carry out all their statutory functions, including commissioning SCRs, until the point at which safeguarding partner arrangements begin to operate in a local area.


1. Serious Case Review Process
  1.1 Criteria for Notifiable Incidents
  1.2 Criteria for Serious Case Reviews
  1.3 Decisions Whether to Initiate a Serious Case Review
  1.4 Methodologies for Learning and Improvement
  1.5 Appointing Reviewers
  1.6 Timescale for Serious Case Review Completion
  1.7 Engagement of Organisations
  1.8 Agreeing Improvement Action
  1.9 Publication of Reports
  1.10 National Panel of Independent Experts on Serious Case Reviews
  1.11 Considerations for Local Processes
  Further Information
  Amendments to this Chapter


1. Serious Case Review Process

1.1 Criteria for Notifiable Incidents

A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected;
  • A Looked After Child has died (including cases where abuse or neglect is not known or suspected); or
  • A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCB or LSCBs promptly, and within five working days of becoming aware that the incident has occurred.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

1.2 Criteria for Serious Case Reviews

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:
    1. Abuse or neglect of a child is known or suspected; and
    2. 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.

“Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCB must commission an SCR.

In addition, even if one of the criteria is not met, 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 secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005. (Working Together to Safeguard Children, 2015)

1.3 Decisions Whether to Initiate a Serious Case Review

The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 1.1, Criteria for Notifiable Incidents) for a Serious Case Review. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).

The LSCB must notify Ofsted, DfE and the National Panel of Independent Experts within 5 working days of the Chair’s decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the National Panel, and require the provision of further information on request and the LSCB chair may be asked to give evidence in person to the panel.

The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCB will also want to review instances of good practice and consider how these can be shared and embedded. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its Annual Report.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. 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 they may choose to commission an alternative form of case review.

1.4 Methodologies for Learning and Improvement

Working Together to Safeguard Children 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it should consider the following 5 principles:

  • 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.

Whilst Working Together stops short of advocating any specific method, the systems methodology as recommended Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

Hull Safeguarding Children Board will continue to develop and ‘test out’ different learning models consistent with the learning principles and will seek to identify the most helpful approach to learning, in the specific context of each particular case.

1.5 Appointing Reviewers

Hull Safeguarding Children Board will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews applying the principles for learning and improvement set out above. Hull Safeguarding Children Board will appoint a suitable individual who has validated experience of leading reviews which is consistent with the Board’s preferred approach to learning in each specific case.

Hull Safeguarding Children Board will provide the National Panel of Independent Experts (see Section 1.10, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.

Working Together to Safeguard Children 2015 does not specify the need for an independent chair for the review process: the need for this will depend on the review model selected, the complexity of the case and other local considerations. The approach should be proportionate to the scale and level of complexity of the issues being examined.

1.6 Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

1.7 Engagement of Organisations

Hull Safeguarding Children Board will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

Hull Safeguarding Children Board may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review. Hull Safeguarding Children Board will communicate clearly at the start of any review process the methodology chosen, the scope of the review and the expectations of each relevant organisation.

Each organisation will identify an appropriate lead for the review. The lead will:

  • Act as the main point of contact for Hull Safeguarding Children Board;
  • Ensure that their respective Hull Safeguarding Children Board member is kept fully briefed on the progress of the review;
  • Ensure that any Chronology and/or written agency analysis of involvement is completed and provided to the lead reviewer within agreed timescales; and
  • Ensure that appropriate support is in place to enable practitioners to engage fully and safely in the learning process;

LSCBs require a person or body to comply with a request for information Section 14B of the Children Act 2004. This can only take place where the information is essential to carrying out LSCB statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCBs should be mindful of the burden of requests and should explain why the information is needed.

1.8 Agreeing Improvement Action

Hull Safeguarding Children Board will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

1.9 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the Hull Safeguarding Children Board website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. Hull Safeguarding Children Board will comply with the Data Protection Act 2018 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

  • 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;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

Hull Safeguarding Children Board will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

Hull Safeguarding Children Board will send copies of all Serious Case Review reports to Ofsted, the Department for Education and the National Panel of Independent Experts at least seven working days before publication. If Hull Safeguarding Children Board considers that a report should not be published, it should inform DfE and the National Panel which will provide advice. Hull Safeguarding Children Board will provide all relevant information to the panel on request, to inform its deliberations.

1.10 National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children 2013 introduced a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews. The panel reports to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.

LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

1.11 Considerations for Local Processes

When initiating a Serious Case Review the Hull Safeguarding Children Board will follow the required procedures and will:

  • Carefully consider and adopt a methodology which will best engage practitioners and their managers and lead to the most helpful learning, taking into account the circumstances of each individual case;
  • Appoint a lead reviewer with the skills and experience to conduct the review in accordance with the preferred approach;
  • Ensure that reviews are coordinated appropriately with any parallel processes (e.g. ongoing criminal proceedings, coronial enquiries etc);
  • Sensitively engage with families, children and other service users, recognising that their perspective can make a valuable contribution to professional understanding;
  • Undertake all reviews with the presumption that they will be published in full;
  • Ensure that children and families are supported appropriately before and after publication, including by sharing with them in advance the main learning from reviews;
  • Ensure that the professionals involved, and their managers, are similarly prepared and supported; and
  • Agree a local publication strategy, including how media interest will be managed.


Further Information

Pathway to Harm, Pathways to Protection: A Triennial Analysis of Serious Case Reviews 2011 to 2014 Final Report (Sidebotham, P et al, DfE, 2016)

Serious Case Review Quality Markers - Supporting Dialogue about the Principles of Good Practice and how to Achieve Them (NSPCC / SCIE, 2016)

NSPCC Serious Case Reviews Repository

Amendments to this Chapter

In January 2017, links were added to the following publications:

  • Pathway to Harm, Pathways to Protection: A Triennial Analysis of Serious Case Reviews 2011 to 2014 Final Report - The study considers a total of 293 SCRs relating to incidents which occurred in the period 1 April 2011 - 31 March 2014 and aims to provide evidence of key issues and challenges for agencies working singly and together in these cases; and
  • Serious Case Review Quality Markers – The Quality Markers have been developed to help support commissioners and reviewers to commission and conduct high quality reviews. They provide a consistent and robust approach to SCRs by covering the whole process from setting up to running the review, to looking at outputs and outcomes from the review.

End.