Referral Form for Consideration of a Case Review

REFERRAL FORM FOR CONSIDERATION OF A CASE REVIEW

Guidance Note
This referral form should be used to refer a case to the Audit and Case Review Sub-Group when it is recognised that there is an opportunity for learning within or across agencies as to how a case has been managed and the outcomes for that child/ren.
Practitioners should highlight these cases to their Manager in the first instance. The Manager should then complete this referral and send it electronically to the LSCB Business Manager at
Name of Referring Agency
Name of Manager
Completing Report
Date of Referral
Contact Details (email, address,telephone number)

CHILD’S DETAILS

Surname
First Name
Any Alias’s
Gender
D.O.B
Home Address
Post Code:
Previous Addresses
Post Code:
Ethnic Group / White
Mixed
Asian or Asian British
Black or Black British
Chinese or other ethnic group
Not known/not stated
Placement Address (if different to home address)
FAMILY DETAILS

Name

/ D.O.B / Parental Responsibility / Address (if different from Child)
Mother
Father
Sibling

OTHER HOUSEHOLD MEMBERS AT FAMILY ADDRESS

Name / D.O.B / Relationship to Child

OTHER SIGNIFICANT PEOPLE

Name

/ D.O.B /

Relationship to Child

DATE OF WHEN CHILD LAST SEEN BY YOUR AGENCY

Date / Circumstance / Seen By

AGENCY INVOLVEMENT

Reason for Agency Involvement.

Please set out a brief case summary / background

Known Service Provision (subject and family/carers) – please note that this includes local and out of authority services
Children’s Social CareAdult Social Care
PoliceGP
Specify the GP’s Name and
Address
HousingEducation
Specify Service(s)Specify Service(s)
Community Health ServicesAcute Health Service
Specify ServicesSpecify Service(s)
Mental Health ServiceDrug/Alcohol Services
Specify Service(s)Specify Service(s)
ProbationVoluntary/3rd Sector
Specify Service(s)
Please outline the reasons for referral (e.g. circumstances of an incident, death, serious injury, referral to protective services, or cause for concern). Include in this section detail of any internal review or single agency investigation being undertaken as a result, and any other action taken in response to concerns identified.

Please tick the appropriate box below that outlines the criteria for the particular review being requested:

Serious Case Review:

Where the subject is a child(ren) and

Abuse or neglect of a child is known or suspected; and the child has died

Abuse or neglect of a child is known or suspected, 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.

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,

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.

Practice Learning Review:

Where the criteria for a serious case review has not been met but 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.

Please briefly outline the gaps in case management/inter-agency working and any learning that you consider may result from a review of this case.

COMPLETED REFERRAL FORMS TO BE EMAILED TO:

Decision of the Panel (for completion by Cheshire West and Chester LSCB Business Manager)

Date of meeting/discussion:
Decision:
Reasons for decision:
Date referrer notified of outcome:

April 2015