Medway Safeguarding Children Board
Notifications and referrals for case reviews to the Medway Safeguarding Children Board.
(Including referral for Serious Case Review)
Approved: January 2015
For review: January 2016
Contents
Introduction: Notification and referrals for case reviews to the Medway Safeguarding Children Board / 2Notifications to the MSCB / 3
Report template / 5
Case Review Referral (Including Serious Case Review) / 6
Referral form for a Case Review Audit / 9
Introduction
Notification and referrals to the Medway Safeguarding Children Board
The safety of children in Medway is our priority and it is everybody’s responsibility.
It is important that professionals and organisations protecting children reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.
To ensure that children are safeguarded properly by agencies working effectively together the MSCB supports a notification and case review referral process.
These processes support the MSCB in celebrating good practice, challenging practice outside of expected standards and procedures and to learn from experiences.
Notifications to the MSCB
1 Introduction
The MSCB aims to learn from incidents where there is learning for multi agency working which would not usually be referred to the MSCB or other body as serious incidents. This will aid continuous improvement to the services we deliver in Medway.
Notifications will include a variety of incidents or examples of good collaborative working, adverse events or prevented incidents. Information from these notifications can help agencies understand why things go wrong and reduce the likelihood of reoccurrence as well as recognising good practice.
The notification process is about learning and feeding back findings and not apportioning blame.
2. Action in the first instance
If there are issues to be resolved then every effort should be made to use exiting policies and procedures to bring issues to the attention of your own or others services. These may include, but are not limited to,
· Consulting with the agency/ies concerned
· Whistle blowing processes
· Complaints procedure
· Escalation protocols
However, if there is learning for the multi agency audience or the above avenues have been exhausted appropriately then a notification to the MSCB may be appropriate.
3. What could a notification be made to the MSCB?
The Medway Safeguarding Children Board encourages the reporting of all significant multi-agency incidents/activities pertaining to the safeguarding of children.
A significant multi-agency safeguarding children incident or adverse event is defined as a situation in which the level of our collective multi-agency response had the potential to impact adversely on the statutory objectives and functions of the MSCB which are as follows:
· To coordinate what is done by each person or body represented on the Board for the purposes of safeguarding and promoting the welfare of children in the area; and
· To ensure the effectiveness of what is done by each such person or body for those purposes.
This includes incidents/adverse events that you have been involved in or witnessed. The incident does not have to have caused harm, or may have caused minimal harm.
You may be able to notify the MSCB of prevented incidents, where good multi agency working has prevented escalation of need or reacted in an emergency to prevent serious harm.
You are also able to notify the MSCB where there has been the Escalation of Concerns Protocol has been instigated but may not have been satisfactory resolved, or has been resolved but the example may be useful for multi agency learning.
Complaints about another service that have remained unanswered by the service or have not improved relations can also be notified.
Examples
Failure of one or more agencies to follow MSCB procedures – even when no harm was caused.
Interpretation of the procedures or actions of an agency, which are questioned by another agency – even when no harm was caused.
When one agency questions another regarding their intended actions and the agency in question then recognises that a different course of action should be taken (prevented incident).
Consistent lack of or miscommunication between two or more agencies.
A complex case where the children had very poor outcomes is turned around by strong multi agency working.
THIS PROCESS DOES NOT REPLACE THE REFERRAL PROCESS FOR SERIOUS CASE REVIEWS/CASE FILE AUDITS/LESSONS LEARNT REVIEWS OR SINGLE AGENCY INDIVIDUAL MANAGEMENT REVIEWS. THESE CONTINUE TO BE CONSIDERED USING THE MSCB REVIEW REFERRAL FORM.
4. How to report
A notification form (Appendix 1) must be completed and sent to the MSCB Learning Lessons Subgroup Chair, via the MSCB support team . The notification should usually be completed by the safeguarding lead. The MSCB will request reports via Learning Lessons subgroup members from any agency involved in the first instance as appropriate and ask that they present their response at the next Learning Lessons subgroup.
5. How are findings shared
The findings will be shared across all agencies in partnership of the Learning Lessons and Learning and Development Subgroups of the MSCB.
The Learning Lessons Subgroup will submit biannual summary reports on incidents to the MSCB.
Appendix 1
Report template: Notification for the MSCB Learning Lessons Subgroup
Date of event/incident/adverse event / TimeService that raised the notification / Section/Division as applicable
Name of informer – / Date of notification
Designation (should usually be the safeguarding lead) / Contact telephone number
Summary of what happened
What measure have already been taken to try and address or resolve the issue?
Summary of contributory causes
Identified areas of good practice
Action taken or recommended to prevent a recurrence
This form should be completed and submitted to the MSCB Support team, Level 5 Gun Wharf, Dock Road, Chatham ME4 4TR
01634 336329
Case Review Referral (Including Serious Case Review)
The case review referral process gives a structure to how agencies notify the MSCB of cases that they feel might warrant a review.
These cases should usually be those that require a multi agency review, or for those that are likely to identify important multi agency lessons.
Statutory guidance, Working Together 2013, identifies the criteria for when the MSCB MUST conduct or consider a Serious Case Review.
1. What cases to refer to the MSCB
1.1 Incidents and circumstances that MUST be referred for case review to the MSCB:
· abuse or neglect of a child is known or suspected; and either
o the child has died; or
o 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. The case must be referred even when it is not clear if there are cause for concerns.
· when a child dies in custody,
o in police custody,
o on remand or following sentencing,
o in a Young Offender Institution,
o in a secure training centre or a secure children’s home,
o or where the child was detained under the Mental Health Act 2005.
This includes cases where a child died by suspected suicide.
· A child sustains a potentially life threatening injury or serious and permanent impairment of health (physical and or mental) or development through abuse or neglect and there are concerns for multi agency working.
· A child has been seriously harmed as a result of being subjected to sexual abuse.
· A parent has been murdered and a domestic homicide review is being initiated.
· The child has been killed by a parent with a mental illness, known to misuse substances or to perpetrate domestic violence.
· A child has perpetrated a particularly serious offence, either against another child or an adult.
· Concerns about inter-agency working that may impact adversely on the safety and wellbeing of identified children and young people.
1.2 Incidents and circumstances that the MSCB advise partners to refer to the MSCB.
The matter should always be discussed the agency safeguarding lead who should take responsibility in the first instance for referral to the MSCB.
If the safeguarding lead is in doubt the matter should be discussed with the MSCB Manager who will offer advice as the chair of the Lessons Learned Subgroup and will take advice from the Chair of the MSCB SCR Screening panel, and/or the MSCB Chair.
Anything where a child suffered significant harm, or was very likely to have suffered harm if there had not been an intervention by any agency, and:
· There was clear evidence of risk of significant harm to a child that was:
o Not recognised by organisations or individuals in contact with the child or perpetrator, or,
o Not shared with others, or,
o Not acted on appropriately
· A child has been abused or neglected in an institutional setting (e.g. school, nursery, children ort family centre, Youth Offending Institutions, Secure Training Centre, children’s home or Armed Services training establishment) and where the abuse is of significant severity and/or failings identified by the notifier ;
· A child was abused or neglected while being looked after by the local authority and where there is some indication that agencies have not done enough or had not taken the opportunity to prevent this. This will also include incidents involving those children placed in Medway by other LA’s. The other Authority will take the lead after being notified by MSCB;
· A child died while absent from or having run away from home or other care setting;
· One or more agency or professional considers that its concerns were not taken sufficiently seriously, or acted upon appropriately, by another and where there is a significant adverse outcome as a result of not being listened to;
· The case indicates that there may be failings in one or more aspects of the local operation of formal safeguarding procedures which go beyond the handling of the specific case;
· The child concerned was the subject of a child protection plan, or had previously been the subject of a plan;
· The case suggests that MSCB may need to change its local protocols or procedures, or that procedures are not being adequately promulgated, understood or acted on;
· There are implications that the circumstances of the case may have national implications for systems or processes or there are significant public interest or community issues.
1.3 Good Practice case review referrals:
Where an agency feels that there are examples of good multi-agency practice demonstrated in a particular case which would provide good learning opportunities and positive outcomes for children this should also be referred to the MSCB for review using the same referral tool.
2. Types of review
Serious Case Review
If the referral form indicates that the referee considers that the threshold for a Serious Case Review has been met a SCR Screening Panel will be convened at the earliest opportunity to consider multi agency information. The decision to undertake a serious case review ultimately rest with the MSCB chair.
Where the threshold for undertaking a serious case review is not met, but where an incident has occurred and there are concerns about multi-agency working to safeguard children and promote their welfare, then the screening panel will consider the need or a lessons learned review or single agency review and refer it to the MSCB Learning Lessons Subgroup/ Case File Audit group or Learning Lessons panel. For example, where a child has died of natural causes, but multi-agency working has been found to be a cause for concern and the review required is more extensive than the Child Death Overview Process.
Lessons Learned Review
A Lessons Learned Review is completed with the same approach to Serious Case Reviews. Each agency concerned will be asked to complete an Individual Management Review that will feed into an overview report. The learning and actions from these reviews will be disseminated through practitioner events and the action plans monitored by the MSCB Learning Lessons Subgroup.
Case File Audit
This is a multi agency review of the case file of the child/ren at a prescheduled regular monthly meeting using the MSCB case file audit tool. The tool addresses why a child/family is known, the concerns relating to the child, what needs to happen and what progress is being made. Extraordinary meetings may be convened to focus on one case.
Good/Practice Review
A professionals forum will be called on an ad hoc basis to consider the practice in individual cases to identify examples of practice in need of improvement, ongoing challenges for professional practice and examples of good practice
Single Agency Individual Management Review
A single agency completes a report as per the Lesson’s Learned Review approach where multiple agencies will be required to complete an Individual Management Review.
Whilst the referee is invited to identify what type of review the case warrants, the final decision rests with the Learning Lessons Subgroup, unless a SCR in indicated and the SCR screening panel will be convened at the earliest opportunity and usually with 1 working week.
In all incidences the Learning Lessons Subgroup will seek to include practitioners and children and their families in reviews as appropriate.
REFERRAL FORM CONSIDERATION FOR A CASE REVIEW/AUDIT
Section 1
1.1 Referrer Details (please ensure full contact details are given as you may be contacted to present the referral and your concerns to the Learning Lessons subgroup)
NamePosition
Agency
Contact Details
Line Manager
Please confirm that your Safeguarding lead endorses this referral? / Yes
Name of Safeguarding Lead
Date of referral
1.2 Child Details