Letter to Essex Police Chief Constable

Serious Case Reviews in Suffolk 2017

1. Purpose of the Case Review Subgroup

The purpose of the Case review subgroup is to:

• Identify and consider referrals for those cases which meet the criteria for a Serious Case Review;
• Identify those cases where lessons can be learned but which do not meet the criteria for a Serious Case Review;
• Identify any themes or trends and to support learning;
• Consider any themes or issues from national Serious Case Reviews that may further improve the quality and impact of safeguarding in Suffolk.
• Ensure that the learning from all case reviewing activity is embedded in practice;
• This guidance should be used in conjunction with Chapter 4 of Working Together 2015 and is supported by the principles of the Suffolk LSCB Learning and Improvement Framework.

2. Scope of the Serious Case Review Subgroup

The SCR subgroup will:

• Review case concerns referred to consider if the Serious Case Review criteria have been met.

For those cases that reach the Serious Case Review threshold, the SCR subgroup will:

• Support the Chair/LSCBManager of the subgroup in outlining the rationale for the Chair’s decision to initiate a Serious Case Review;
• Support the development of the draft terms of reference for the Serious Case Review and consider the methodology for carrying out the review;
• Depending on the type of review, identify a potential independent reviewer with the relevant skills and knowledge to conduct the review and produce a final multi-agency report;
• Identify the multi-agency review team;
• Outline the membership for the Serious Case Review Panel;
• Monitor the implementation and impact of any multi-agency lessons to be learned;
• Ensure the outcome has been shared with National Serious Case Review Panel, DfE and Ofsted.

For those cases that fall below the Serious Case Review threshold, the SCR subgroup will:

• Support the Chair/LSCB manager in developing the rationale to not initiate an SCR if one has been requested;
• Determine if there is relevant possible learning from the case and recommend the process and methodology for understanding the learning;
• Ensure, where relevant the outcome has been shared with National Serious Case Review Panel, DfE and Ofsted;
• Identify who needs to contribute to the review;
• Outline the terms of reference for the review and the methodology for carrying out the review;
• Identify a timescale for the review and submission of any reports;
• Translate learning and challenges into action; outlining how the impact and effectiveness of any response will be evaluated.

In addition, the SCR subgroup will:

• Identify relevant SCRs in other LSCB areas to further develop and enhance local safeguarding practice;
• Agree a model to evaluate how learning from any statutory or non-statutory reviews commissioned has been implemented, including impact on practice.

3. How to Make a Referral to the SCR Subgroup?

For advice regarding whether a case should be referred to the Serious Case Review subgroup, please contact the named or designated safeguarding lead/SCR subgroup representative in your organisation in the first instance. They will then discuss with the Chair of the SCR subgroup or LSCB Manager and make them aware of your intention to refer the case for consideration.

The CR1 referralform is to be used to describe the reason for the referral. Once the referral has been processed, this form will be used to outline the rationale for the decision of the Chair of the subgroup as to the course of action to be taken.

4. Making the Decision to Initiate a Serious Case Review

When the referral form regarding a request for any case review is received by the LSCB, it will be considered by the Chair and the LSCBManager. If the chair and LSCBManager sees the referral as appropriate, it will be placed on the agenda and a meeting will be convened. At this point, the referring agency may be asked to provide further information.

All relevant agencies will be asked to submit a brief précis of their involvement with the child, its siblings or any family members identified in the referral. This will be shared with the SCR subgroup members to inform the discussion and recommendations about the referral.

Information about the involvement of agencies with the child and the family will be shared by the relevant member and a discussion regarding whether the case fits the criteria for an SCR is met. Each agency’s representative (voting members only) will be asked to offer their recommendation to the chair as to whether to initiate.

Should the information suffice, the Chair of the SCR subgroup will either make a decision at the SCR meeting (in cases which clearly fit the criteria) or will defer the decision, indicating to the SCR subgroup the reason for deferring and requesting any further information that may inform the decision.

The decision will normally be deferred for a week after the SCR subgroup, during which there will be the opportunity for the chair to reflect on the information or request more information and for agencies to have further discussion with the chair of the SCR subgroup as regards the decision to initiate a Serious Case Review.

Once the Chair and LSCBManager has made this decision it will be recorded and will be shared via email with all of the agencies that attended the SCR subgroup that discussed the referral, and with the referring agency’s LSCB Board member, and the Director of Children’s Services, Chair of the full board and the Chief Executive of the Local Authority.

5. Where there is no Serious Case Review Requested or Initiated from the Referral

Where the threshold for a Serious Case Review is not met and it is clear that the child’s death had no medical cause, the SCR subgroup will consider alternative ways of learning about the safeguarding practice/system. This could include:

• Single agency management reviews;
• Multi-agency or Partnership reviews;
• Single or multi-agency theme based case audit;
• Peer Review/mentoring between local agencies.

6. Serious Case Review Subgroup Membership

The current chair of the subgroup is Sue Hadley – LSCB Independent Chair.

Case Review Panel Membership:

• LSCB Independent Chair
• LSCB Manager
• SCC CYPS
• CCG
• Suffolk Constabulary
• SCC Legal Services
• Cafcass.

NB:Other members may be co-opted for specific cases to reflect the characteristics of the local population (for example, a representative of a large local ethnic or religious community), to provide a perspective from the independent or voluntary sector, or to contribute to the discussion of certain types of reviews (for example, fire fighters for house fires).

Frequency of Meetings:

Six weeks prior to a LSCB Board Meeting and two weeks after a LSCB Board Meeting.

Overall, there will be eight meetings a year.

Panel members represent their agency and will be required to ensure that their agency’s views and opinions are represented. Panel members will also be expected to provide their expertise and knowledge of best practice in their field to ensure that the panel is well advised.

7. Appointing a Review Panel to oversee a Serious Case Review

When a Serious Case Review is initiated, and the reviewer has been appointed and the terms of reference approved by the SCR subgroup, the case will then be overseen by a panel (review team). Membership will consist of representatives from all agencies providing an agency report.

The representative will have oversight of the work of the review and will quality assure the work. The review team meetings will be chaired by an independent reviewer, or the chair of the SCR subgroup. The panel will meet at critical points in the review to ensure that the Terms of Reference are appropriate and are being met by the work of the reviewer. The LSCB Manager and a minute taker will attend and where required, legal advice will be sought/legal advisor will be in attendance, as will expert advice if the panel deem this necessary.

8. National panel of independent experts on Serious Case Reviews

From 2013 there has been a national panel of independent experts to advise LSCBs about the initiation and publication of SCRs. The role of the panel will be to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel will also report to the Government their views of how the SCR system is working.

The panel's remit will include advising LSCBs about:

• application of the SCR criteria;
• appointment of reviewers; and
• publication of SCR reports.

The LSCBs should have regard to the panel’s advice when deciding whether or not to initiate an SCR, when appointing reviewers and when considering publication of SCR reports. LSCBsChairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of SCR reports and invitations to attend meetings.

In doing so, LSCB will be exercising their powers under Regulation 5(3) of the LSCB Regulation 2006 which states that ‘an LSCB may also engage in any other activity that facilitates, or is conducive to, the achievement of its objective’.

9. Organisational Arrangements of the SCR Panel

The SCR subgroup meets bi-monthly. The meetings will be set for a year ahead.

Members of the group will be required to submit any agenda items and supporting documents to the Chair via the LSCB or LSCB Manager at least 7 working days prior to the meeting.

Agendas and documentation will be sent to attendees by email at least 5 working days before the meeting.

The SCR subgroup will contribute to the Learning and Improvement framework report which is reported on an annual basis to the LSCB in as part of the LSCBAnnual Report and Business Plan.

10. Confidentiality

These cases can be subject to high levels of public interest and complex legal processes in the criminal and civil courts. Reviewers/Authors, panel members and any others involved with the Serious Case Review process need to be clear that the information they learn about the case and agency’s involvement is confidential. This means it should not be discussed with anyone apart from key agency members within the agency who are responsible for either the current case management, where information is required to manage the case or the senior managers in the agency who need to be kept informed to achieve the agency’s approval.

11.Informing the Department for Education

In all cases the decision made as to whether an SCR will be initiated will be shared with the Department for Education - and details of the Author/Reviewer, when appointed, sent to the National SCR Panel - .

12.SCR Reviews with parallel criminal investigations

When an SCR is undertaken whilst there is an ongoing police investigation, it is important that the two processes link with attention to disclosure requirements.

There is a presumption that even when criminal proceedings are ongoing, the work of the Review will go ahead in accordance with the Government timescales unless there are special circumstances which would require some compromise. If there are clear reasons put forward by the Police or CPS in discussion with the SCR Independent Reviewer it may be possible to negotiate a delay in final completion of the SCR, or some restriction of its scope such as consideration being given to not interviewing or involving specific people who may be key witnesses or defendants in criminal proceedings.

13.Timescale

Where possible the SCR will aim to be completed within the SCR framework of six months (Working Together 2015), subject to exceptional circumstances. Should an organisation fail to submit relevant information requested by the Board within the agreed timescales, the review will continue to publication and these failures willbe highlighted within the report.

Appendix 1: Serious Case Review Regulations

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.

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 final decision on whether to conduct the SCR rests with the LSCB Chair. 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.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. They will also want to review instances of good practice and consider how these can be shared and embedded. LSCBs are free to decide how best to conduct these reviews. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

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Appendix 2: Case Review Decision Matrix

This matrix identifies the potential outcomes from a referral and should support the initial screening and decision-making process. Initial referrals will be screened by the LSCB Business Manager and the chair of the SCR subgroup resulting in a recommendation being made on how to progress.

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Appendix 3: Timeline

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