Learning and Improvement Framework
(Notifiable Incidents, Serious Case Reviews, Case Reviews and other alternative reviews Procedures and Guidance)
Version / 1
Date / 03.02.2016
Author / Heather McFarlane
Edited by: / Emma Chawner/Amanda Hugill
Update and Approval Process
Version / Group/Person / Date / Comments
1 / DSCB Policy and Procedure Group / June 2015
2 / DSCB Policy and Procedure Group / 09.02.2016 / Minor amendments – resources links inserted and version control
3 / DSCB Case Review and Learning from Practice Sub Group / 17.1.17 / Approved
4 / LSCB / 25.1.17 / Approved
Issue Date / 25th January 2017
Review Date / January 2018
Reviewing Officer
Contents
Number / Section Title / Page(s)1 / Introduction / 3
2 / Statutory Duty - under LSCB regulations / 3-4
3 / SCR criteria / 4-5
4 / Levels of Serious Case Reviews / 5
5 / Purpose and Principles / 5-6
6 / SCR Methodology / 6
7 / Initiating an SCR / 6-7
8 / Decision Making / 8
9 / SCR Screening Panel / 8-9
10 / Commissioning an SCR / 9-10
11 / SCR Panel / 10
12 / Interface with other reviews and investigations / 10-11
13 / Engagement of Families / 12
14 / Considerations for Disclosure in SCR / 12
15 / Publication of Reports / 13
Appendix 1 / SCR methodologies and Tools / 14-18
Appendix 2 / Case referral form / 19-23
Appendix 3 / Decision Making Matrix / 24-27
Appendix 4 / Timeline for Decision making / 28
Appendix 5 / Chronology template / 29
Appendix 6 / Recommendations to DSCB / 30
Appendix 7 / Stages of SCR / 31-32
1. INTRODUCTION
1.1Local Safeguarding Children Board (LSCBs) are a statutory requirement under the Children Act 2004 (section 13) and the main objectives of LSCBs are:
(a) 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
(b) To ensure the effectiveness of what is done by each such person or body for those purposes.
1.2DarlingtonSafeguarding Children Board (DSCB)should also maintain a local learning and improvement framework that enables organisations to be clear on their responsibilities, to learn from experience and improve services as a result. This includes the duty to conduct any Serious Case Reviews (SCRs) in accordance with Regulation 5 of the LSCB 2006 Regulations. SCRs are reviews that examine the way agencies and individuals that have been involved with a child/ren have acted when abuse or neglect are suspected or known. The purpose of a SCR is to identify learning that will bring about improvements so that the likelihood of harm to children is minimised.
1.3DSCB may also arrange for there to be a review of any other case involving a child/ren in its area with a view to identify lessons to be learned from the child/ren’s case, and to apply the learning to future cases. In addition, cases where there is good practice can also be considered to identify learning that can be applied to future cases.
1.4This procedure specifies the statutory requirements and the working arrangements of DSCB in respect of SCRs, notifiable incidents and alternative learning from case reviews.Including any interface with other reviews such as Domestic Homicide Reviews (DHR), Youth Offending Service (YOS) reviews and Multi-agency Public Protection Arrangements (MAPPA) reviews.
2. STATUTORY DUTY UNDER REGULATION 5 OF THE LSCB 2006 REGULATIONS
2.1Notifiable Incidentsrefer to 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[1]
- 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).
Refer to DSCB Notifiable Incident Procedure and Practice Guidance for information on reporting notifiable incidents to Darlington Borough Council.
2.2Serious Case Review is 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.
2.3Each member of DSCB must co-operate in and contribute to the carrying out of a review under this section with a view to:
(a) identifying the lessons to be learned from the child/ren’s case, and
(b) applying those lessons to future cases.
3. SCR CRITERIA
3.1The first criterion for determining whether a SCR should be conducted is establishing whether the child/ren reside in the Darlington area. If the child’s homeis normally resident in another local authority area, this information must be shared with the home LSCB.
3.2 Working Together 2015 guidance clarifies the term “seriously harmed” and the definition reads as:
- 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. DSCB should ensure that their considerations on whether serious harm has occurred are informed by 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 a SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide (where abuse or neglect is known or suspected). 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 DSCB must commission a SCR.
In addition, even if one of the criteria is not met, a SCR should always be carried out when a child dies in custody, police custody, on remand or following sentencing,in a Young Offenders Institution, or in a 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 years was the subject of a deprivation or liberty order under the Mental Capacity Act 2005.
3.3The second criterion to be met is establishing a cause for concern: How DSCB, its member organisations, or other persons with relevant functions, worked together to safeguard the child/ren. A particular emphasis is the extent that they could have worked more effectively to protect the child/ren from the resultant outcome and therefore the potential for learning.
3.4The third criterion involves:An examination of the link between the death or (other outcome) and suspected abuse or neglect.
3.5In the context of SCRs, something can be considered serious abuse or neglect where, for example; the child/ren would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity (16-17 year olds) or quality of life as a result of the abuse or neglect.
4. LEVELS OF SERIOUS CASE REVIEWS
4.1DSCB will utilise two levels of SCR’s
- A level 1 (Statutory) SCR will be required for those circumstances in which DSCB must arrange a SCR.
- A Level 2 (Discretionary) SCR may be conducted in any other situations
4.2It is to be noted that the review methodology selected will not be pre-determined by the level of the SCR but after consideration of the particular circumstances of each case, seeking the views of the child/ren, parents/carers and or relatives and with reference to the purpose and principles. In any SCR the approach should be proportionate to the scale and complexity of the issues and the potential for learning.
5. PURPOSE AND PRINCIPLES OF A SERIOUS CASE REVIEW
5.1The purpose of a SCR is to promote effective learning and improvement action, through identifying what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. It is not an investigation.
5.2The SCRs purpose is not to hold any individual or organisation to account as other processes exist for that. These include criminal proceedings, disciplinary procedures, employment law and those of relevant service and professional regulatory bodies.
5.3A SCR should highlight any lessons that can be learned from the case and through a clear set of recommendations; ensure that relevant actions are taken in order to help prevent future deaths or serious harm. This helps to improve both single and inter agency working and better safeguard and promote the welfare of children.
5.4SCRs will be undertaken in accordance with the following principles:
- Child/ren is at the centre of the process
- Voice of the user: Every effort must be made to ensure the voice of the child/ren or their parents/carers is evident throughout the process
- Learning culture: There should be a multi-agency culture of continuous learning and improvement and to promote good practice
- Proportionate: The approach should be proportionate according to the scale and complexity of the issues and the potential for learning
- Involvement of practitioners and clinicians: Professionals should be fully involved in reviews and invited to contribute their perspective without fear of blame for actions they took in good faith.
- Transparency:SCRs should be trusted and safe experiences that encourage honesty, transparency and sharing of information.
- Independent: SCRs should be led by individuals who are independent of the case and of the organisations whose actions are being reviewed
- Embedding learning: using a range of creative communication and methodologies
- Sustainability: improvement must be sustained through regular monitoring and following up the findings from these reviews that make a real impact on improving outcomes for children
5.5DSCB should be primarily concerned with determining what type of review process best enables this to happen. The level of the review will be determined by the Chair of DSCB following a recommendation from the SCR Screening Panel.
5.6The findings from SCR’s will be included in DSCB’s annual report along with relevant service improvements and actions and the reasons for any decisions not to implement actions.
6. SCR METHODOLOGY
6.1DSCB will give consideration to the most appropriate methodology to use as no one model will be appropriate for all cases. The most appropriate methodology will normally be that which provides the best opportunity to learn; however it will be determined by and proportionate to the specific circumstances and the scale of the situation.
6.2Any of the methodologies may be used for any type of case. Methodologies that would usually be considered for the most serious cases include traditional SCR, safeguarding adult review (SAR) domestic homicide reviews (DHR), action learning and peer review approaches. Other methodologies include but are not confined to a multi-agency practice learning review, a root cause analysis, or a significant event review. There is flexibility in determining the precise process, including variations and combinations of methodology elements on a case by case basis. (See Appendix 1 for additional information on review tools and methodologies).
7. INITIATING A SCR
7.1Only DSCB can commission a SCR in Darlington. However any agency or individual can refer a case for consideration of whether it meets the criteria for a SCR.
7.2Where any individual or agency believes or suspects there may have been circumstances where the threshold for holding a SCR has been met, they may refer a case to the Chair of DSCB via the Business Manager to establish if there are important lessons for multi-agency work to be learned from a case. This includes any professional body, members of the public, councillors, MP’s and the coroner. The Secretary of State also has authority under the Local Authority Social Services Act (1970) to cause an enquiry to be held where he/she considers it advisable.
7.3A referral is made by completing the referral form (see appendix 2) detailing why you (as the referrer) believe the case meets the criteria for a SCR. Referrals should be made as soon as it is apparent that the criteria may be met, subject to considerations in paragraphs 7.4 and 7.5 below. An unreasonable delay in raising an issue can impact both on the process and the key purpose.
7.4It is good practice and expected standards to ensure the family are informed that an agency is making a referral to the CR&LP subgroup and to seek adults consent to share their relevant information for the purposes of the SCR/LLR or alternative review/audit to establish the learning to inform multi-agency practice. If this is not done, there must be a clear rationale for why consent has not been sought.
7.5In order to ensure the optimum effectiveness and learning from the resources employed, DSCB will not normally review cases that are more than twelve months old, unless significant information emerges, or there were good reasons why the SCR was not deemed appropriate at an earlier stage.
7.6Prior to making a referral, professionals working with children, should consider the relevant guidance, and seek assurance from their line manager, Designated Safeguarding Lead or DSCB representative.
7.7There may be more than one child that is being considered for a SCR, it is important to ensure each review process considers each child’s perspective and experience individually but ensure the learning arising from the children’s circumstances is brought together in one comprehensive review report at the conclusion of the review.
7.8By virtue of the criteria, in cases where a SCR may be indicated, a safeguarding concern and/or enquiry may already have been made. In this case a discussion with the relevant children’s services team manager should normally take place prior to making a referral for a SCR. Consideration of whether a SCR is required should never delay the raising of a safeguarding concern and the adherence to multi-agency safeguarding policy and procedures which considers any immediate protection required.
7.9However, there may be circumstances where safeguarding concerns are not obvious or evident, for example, where the child/ren may have died as a result of suicide (where abuse or neglect are known or suspected) and there are concerns that partner agencies could have worked more effectively to protect the child.
7.10In these cases a formal consultation with the Independent Chair of DSCB must take place and a discussion may also be held with the CR&LP sub group Chair.
7.11All agencies have their own internal or statutory procedures to investigate serious incidents and to promote reflective practice or learning, and this protocol is not intended to duplicate or replace these. However consideration of this protocol must be considered when agencies undertake internal reviews or when investigating serious incidents.
8. DECISION MAKING
8.1On receipt of the SCR referral request, the Director of Children and Adult Services as the statutory safeguarding lead and the Chair of DSCB will be notified by the Safeguarding Boards’ Business Unit. The Independent Chair will consider the information provided prior to triggering the next stage of the SCR screening process. The chair may seek further information including clarity about parallel investigations that may be taking place. In some circumstances, the Chair of DSCB may decide not to progress further with a referral at this stage and instead recommend further actions. In this case, the reasons for this will be recorded and a response and explanation provided to the referrer. All referrals will be recorded and noted at the Case Review and Learning from Practice Subgroup (CR&LP). Attached as appendix 4 is the suggested timeline.
8.2The Chair of DSCB will request that the CR&LP subgroup convenes a screening panel at the earliest opportunity to make sure that learning and development takes place so that children are safeguarded more effectively and their welfare is promoted.
8.3The SCR screening panel will meet to consider the information in order to make recommendations to DSCB Independent Chair on whether a SCR should or should not be held and on application of the criteria, the level. On conclusion of the meeting, the chair of the CR&LPsubgroup will write to DSCB chair (see appendix 6) with the outcome and the rationale on which it is based (within 24 hours or as soon as is practicable).
8.4Once the Chair of DSCB has received the recommendation, they will make the final decision about whether a SCR should take place. DSCB chair will then notify the Chair of the CR&LP and the Director of Children and Adult Services using the appropriate form (appendix 6) via the Business Manager.
8.5In the event of DSCB Chair’s decision that a SCR should not take place, the reasons must be recorded and shared with the referrer and DSCB. When this is the case and there is a parallel investigation or review process taking place, or if the Chair of DSCB commissions an alternative process, arrangements should be made for the relevant findings to be reported to DSCB via the CR&LP subgroup. The CR&LP subgroup will then ensure that learning can be disseminated and shared across other agencies and where relevant other regional and national networks.
8.6The Independent Chair will also write to the National Panel of Independent Experts of their decision to undertake an SCR or not.
9. THE SCR SCREENING PANEL
9.1The SCR Screening Panel needs to have the information and expertise required to make the recommendation. It will consist of members of the CR&LP subgroup, supplemented with any additional individuals or organisations with the necessary knowledge or expertise pertinent to the circumstances of the case. The SCR Screening Panel may also wish to have available specialist advisers whose role will be to advise it during the process.
9.2The SCR Screening Panel will be provided with written reports from the key agencies involved. Representatives from agencies may also be asked to attend during the first part of the panel meeting, to help clarify the circumstances of the case. It is important for the panel to have sufficient information before discussion begins. However the panel is not investigating the circumstances of the incident, and is not conducting the SCR themselves, so the consideration of issues should be proportionate.