7.1 Serious Case Reviews

The Oxfordshire Safeguarding Children Board undertakes Serious Case Reviews into the involvement with a child and their family of organisations and professionals when the child has died or is seriously injured and the criteria as set out in Section 2, Criteria are met. The purpose of the Review is to consider whether there are any lessons to be learnt from the case regarding the ways in which agencies work together to safeguard and promote the welfare of children.

When a child dies or is seriously injured, and abuse or Neglect is known or suspected to be a factor, local organisations should consider immediately whether there are other children at risk of harm who require safeguarding (e.g. siblings or other children in the household or other children in an institution where abuse is alleged).

The purpose of undertaking a Serious Case Review is to:-

• Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children;
• Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and
• As a consequence, improve inter-agency working and better safeguard and promote the welfare of children.

The Oxfordshire Safeguarding Children Board should always consider undertaking a Serious Case Review where:

• A child sustains a potentially life threatening injury or serious and permanent impairment of health and development through abuse and neglect; or
• A child has been subjected to particularly serious sexual abuse; or
• A parent has been murdered and a homicide review is being initiated; or
• A child has been killed by a parent with a mental illness; and/or
• The case gives rise to concerns about inter agency working to protect children from harm

Any professional may refer a case to the Oxfordshire Safeguarding Children Board (after appropriate consultation with his/her line manager, Designated Professional or Named Professional) where it is believed that the criteria for a Serious Case Review are met (see Section 2, Criteria).  If so:

A referral should be made to Head of Service, Early Years & Family Support, Children, Young People and Families who will immediately inform * the Director of Children, Young People and Families, the Chair of the Oxfordshire Safeguarding Children Board (if different) and the Board's Core Group verbally and in writing.

If it appears that the criteria for a Serious Case Review are met, the Service Manager, Safeguarding and Quality Assurance or his/her nominated representative will send a letter (on behalf of the Oxfordshire Safeguarding Children Board Chair) to the Chief Executives or equivalent of the relevant agencies with copies to the named professionals, within 5 working days of receiving notification of the child’s death/serious injury and relevant concerns, to request agencies to secure their files and records.

The letter will include:-

• Names, dates of birth and addresses for the child and other children who are a part of the household
• Names, dates of birth and addresses of the parents/carers and key adults
• Brief circumstances of the case
• School or nursery attended
• GP Practice

To assist the Panel in determining whether to recommend that a Serious Case Review should be convened, the following questions should be taken into account:

• Was there clear evidence of a risk of Significant Harm to a child, which was:
  • not recognised by organisations or individuals in contact with the child or perpetrator? or
  • not shared with others? or
  • not acted upon appropriately?
• Was the child killed by a mentally ill parent?
• Was the child abused in an institutional setting? (for example, school, nursery, family centre, YOI, STC, Children’s Home or Armed Services training establishment)
• Did the child die in a custodial (prison, young offender institution or secure training centre) setting?
• Was the child abused while being Looked After by the local authority?
• Did the child commit suicide, or die while absent having run away from home?
• Does one or more agency or professional consider that its concerns were not taken sufficiently seriously, or acted upon appropriately, by another?
• Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding children procedures, which go beyond the handling of this case?
• Was the child the subject of a Child Protection Plan or had is/he previously been the subject of a Child Protection Plan or on the Child Protection Register?
• Was another child in the same household or family the subject of a  Child Protection Plan - or had s/he previously been the subject of a Child Protection Plan or on the Child Protection Register?
• Does the case appear to have implications for a range of agencies and/or professionals?
• Does the case suggest that the OSCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately promulgated, understood or acted upon?

The Serious Case Review Panel having considered all the information available to it (including information for any review of the child’s death by a Child Death Overview Panel), can make the following recommendations to the Chair of the Oxfordshire Safeguarding Children Board:

1. To  conduct a Serious Case Review
2. To defer a decision until more information is available (e.g. Coroner’s report) and/or reconvene the Serious Case Review Panel.
3. To require agencies to undertake Individual Management Reviews (see Section 8, Individual Management Reviews) within set timescales.
4. To undertake a smaller-scale audit of cases which do not meet the criteria for Serious Case Reviews within a set timescale.

Note: For iii. and iv., agencies will be expected to make arrangements to share relevant findings with the Serious Case Review Panel when their reviews and audits have been concluded.

Where the Serious Case Review Panel recommends that a Serious Case Review be undertaken, it should consider, in the light of each case, the scope of the review process, and draw up clear terms of reference.  Relevant issues include:

• What appear to be the most important issues to address in trying to learn from this specific case? How can the relevant information best be obtained and analysed?
• Who should be appointed as the independent author for the Overview Report?
• Should additional members of the Serious Case Review Panel be appointed in order to accurately reflect the involvement of the relevant agencies?
• Which organisations and professionals should contribute to the Serious Case Review? including, where appropriate, for example, the proprietor of an independent school, a playgroup leader or a refuge manager; who should be asked to submit reports or otherwise contribute?
• Are there features of the case which indicate that any part of the review process should involve, or be conducted by, a party independent of the professionals/organisations who will be required to participate in the review? Might it help the Review Panel to bring in an outside expert at any stage, to shed light on crucial aspects of the case?
• Over what time period should events be reviewed, i.e. how far back should enquiries cover and what is the cut-off point? What family history/background information will help better to understand the recent past and present?
• How should family members contribute to the review and who should be responsible for facilitating their involvement? See Section 6, Involvement of Family Members and Access to Third Medical Records.
• Will the case give rise to other parallel investigations of practice, for example, independent health investigations or multi-disciplinary suicide reviews, a homicide review where a parent has been murdered, a Youth Justice Board Serious Incident Review and a Prisons and Probation Ombudsman investigation where the child has died in a custodial setting? And if so, how can a co-ordinated or jointly commissioned review process best address all the relevant questions which need to be asked, in the most economical way?
• Is there a need to involve organisations/professionals in other Local Safeguarding Children Board (LSCB) areas, and what should be the respective roles and responsibilities of the different LSCBs with an interest?
• How should the review process take account of a Coroner’s Inquiry, and (if relevant) any criminal investigations or proceedings related to the case? How best to liaise with the Coroner and/or the Crown Prosecution Service?
• How should the Serious Case Review process fit in with the processes for other types of reviews e.g. for homicide, mental health or prisons?
• Who will make the link with relevant interests outside the main statutory organisations - e.g. independent professionals, independent schools, voluntary organisations?
• When should the review process start and by what date should it be completed?
• How should any public, family and media interest be managed, before, during, and after the review?
• Does the LSCB need to obtain independent legal advice about any aspect of the proposed review?
• How will the Regulatory Authority be kept updated?

At the outset of the Serious Case Review process:

With regard to family members, in determining the scope of the review, the Serious Case Review Panel should determine:

• Which family members should be invited to contribute to the review, how they should be engaged and who should be responsible for facilitating their involvement and
• Which family members’ and/or third parties’ medical and/or other records need to be accessed to inform the internal management reviews and chronology

Representatives identified by the Serious Case Review Panel should arrange to meet with the relevant family members/third parties to explain the process, invite their participation and explain the need to access their records.

If they object, they should be advised of their right to seek legal advice.

Any agencies or practitioners who will be required to share information as part of the Serious Case Review process will be written to by the Serious Case Review Panel Chair confirming that the above has taken place and that they should therefore share the relevant information.

On accepting the Overview Report:

The Serious Case Review Panel should:

• Make arrangements to provide feedback and debriefing to family members (WT para 8.29)
• Consider who might have an interest in the review – e.g. elected and appointed members of authorities, staff, members of the child’s family, the public, the media – and what information should be made available to each. (WT para 8.32)
• Identify who will take responsibility for debriefing family members.

In all cases, the Overview Report should contain an Executive Summary (see Section 11, Steps to be taken when the Overview Report is Completed) that will be made public and that includes, as a minimum, information about the review process, key issues arising from the case and the recommendations that have been made. (WT para 8.33)

As a part of an Individual Management Review, each agency will:

1. Determine who will undertake the Individual Management Review. The person must not have been directly concerned with the child or family and must be independent of the line management for the case and must be given sufficient time and resources to undertake the task.
2. Ensure all the relevant information is obtained to complete the Individual Management Review;
3. Inform key staff that an Individual Management Review is to be undertaken and the process for feedback, support and de-briefing, in advance of the completion of the Overview Report.  Staff should also be instructed not to disclose any information verbally or in writing to anyone outside the agency with prior agreement of the agency’s senior management
4. Compile a Genogram in an agreed format.
5. Compile a Chronology of all records of involvement including correspondence and telephone calls. An agreed template for the chronology must be used to assist compilation of the composite chronology. The chronology should include and summarise each contact, setting out decisions made, services provided and actions taken.
6. Conduct interviews of individual staff where required for the purpose of clarifying information obtained from the written records. The conduct of these interviews needs to be sensitively handled and be mindful of any agency disciplinary procedures. A written record of each interview should be made and shared with the interviewee.
7. Where, during the collation of information, the author of the Individual Management Review comes across information that they believe is relevant and informative but outside the dates of the commissioned report, they should include such information as background information.
8. Compile the report following the agreed format.  Staff and family members should be suitably anonymised in the report and chronology. A list of the abbreviations used should be forwarded with the report. The report should include information on what files/records were read, who was interviewed and what procedures were referred to.
9. Complete an analysis of involvement, lessons to be learnt and recommendations for action. Any immediate action required must be highlighted.
10. Submit the completed Individual Management Review Report for approval to the senior officer in the agency who has commissioned the report; the senior officer will be responsible for ensuring the quality and accuracy of the report and determining any immediate action to be undertaken arising from the recommendations of the Individual Management Review, and ensuring that the recommendations are acted upon.
11. Consider the need for a follow-up feedback session where issues for the agency and its staff are raised
12. Consider the need for any disciplinary action

An Individual Management Review must analyse the agency’s involvement and consider the events that occurred, the decisions made and the actions taken, which indicate that practice or management could be improved. The Review must try to get an understanding not only of what happened but why.  It should consider especially the following;

• Were practitioners sensitive to the needs of the children in their work, knowledgeable about potential indicators of abuse or Neglect, and about what to do if they had concerns about a child?
• Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?
• What were the key relevant points /opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?
• Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquiries made, in the light of assessments?
• Where relevant, were appropriate child protection or care plans in place, and child protection and /or Looked After reviewing processes complied with?
• When, and in what way, were the children’s wishes and feelings ascertained and taken into account when making decisions about services? Was this information recorded?
• Was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?
• Were senior managers or other organisations and professionals involved at points were they should have been?
• Was the work in this case consistent with each organisation’s and the Oxfordshire Safeguarding Children Board’s policy and procedures for safeguarding and promoting the welfare of children (as set out in this Manual), and with wider professional standards?

Responsibilities of the Chair of the Serious Case Review Panel

They are:

1. To exercise independence of the key agencies who have undertaken the Individual Management Reviews.
2. To comply with the terms of reference.
3. To make arrangements in consultation with Panel Members to seek the view of the parents/carer if appropriate (see Section 6, Involvement of Family Members and Access to Third Party Medical Records).
4. To ensure a programme of meetings with a timescale for completion, to be agreed with the Regulatory Authority.
5. To arrange for the Chair of the Oxfordshire Safeguarding Children Board to be updated on the progress of the Panel monthly or as otherwise agreed.
6. To send the draft Overview Report to members of the Panel,
7. To ensure that the Overview Report is based on fact and is open, honest and transparent with no suggestion of malice either in the report or in its dissemination.
8. If any additional enquiries arise, to arrange for these to be answered through the author(s) of the relevant agency’s Individual Management Review or other appropriate Officer. The Chair or Panel would not usually be expected to interview officers.
9. If further concerns e.g. child protection arise during the course of the Panel’s work, to arrange to inform the Chair of the Oxfordshire Safeguarding Children Board/Police/Children, Young People and Families immediately. The Panel must not investigate.
10. To ensure clear, robust, meaningful recommendations that will bring about service change.
11. To forward the final Overview Report to the Chair of the Oxfordshire Safeguarding Children Board who will consider the report and discuss any amendment or clarification required with the Chair of the Panel before submission to the Board for ratification.
12. To agree proposals for the dissemination of reports and handling of the media - to be agreed by the Chair of the Oxfordshire Safeguarding Children Board.

Responsibilities of Panel Members

They are:

1. To have appropriate experience and expertise
2. To have had no direct involvement with the child or family either as a practitioner or a manager.
3. To comply with the Terms of Reference.
4. To make additional enquiries of the author(s) of the Individual Management Review Report as necessary.

Overview Reports will vary according to the particular circumstances of each case but they must cover the following areas:           

Introduction

• Summarise the circumstances that led to a review being undertaken in this case
• State the terms of reference of the review
• List the contributors to the review and the nature of their contributions, the Panel members and the author of the Overview Report

The Facts

• Prepare a Genogram showing membership of family, extended family and household
• Compile an integrated Chronology of involvement with the child and family on the part of all relevant organisations, professionals and others; note specifically each occasion on which the child was seen and the child’s wishes and feelings were sought or expressed
• Prepare an overview that summarises what relevant information was known to the agencies and professionals involved about the parents/carers/, any perpetrator and the home circumstances of the children.

Analysis

This part of the Overview Report should examine how and why events occurred, decisions were made and actions were taken or not taken. The Panel should consider, with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events. Any examples of good practice should be included here.

Conclusions and recommendations

The lessons to be drawn from the case and how those lessons should be translated into recommendations for action should be set out.  The recommendations should include those made in the individual reports from each organisation. The recommendations should be focused and specific and capable of being implemented.  Any lessons for national as well as local policy and practice should be highlighted. 

There are difficult interests to balance, among them:

• the need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others;
• the accountability of public services and the importance of maintaining public confidence in the process of internal review;
• the need to secure full and open participation from the different agencies and professionals involved;
• the responsibility to provide relevant information to those with a legitimate interest;
• constraints on sharing information when criminal proceedings are outstanding, in that access to the contents of information may not be within the control of the Oxfordshire Safeguarding Children Board

Reviews are of little value unless lessons are learned from them.  At least as much effort should be spent on acting upon recommendations as on conducting Reviews.  The following may help in getting maximum benefit from the review process:

• as far as possible, conduct the review in such a way that the process is a learning exercise in itself, rather than a trial or ordeal;
• consider what information needs to be disseminated, how, and to whom, in the light of a review.  Be prepared to communicate both examples of good practice and areas where change is required;
• focus recommendations on a small number of key areas, with specific and achievable proposals for change and intended outcomes;
• the Oxfordshire Safeguarding Children Board should review and monitor agency Action Plans and put in place a means of auditing action against recommendations and intended outcomes;
• seek feedback on Overview Reports from the Regulatory Authority who should use reports to inform inspections and performance management.

Day to day good practice can help ensure that reviews are conducted successfully and in a way most likely to maximise learning:

• establish a culture of audit and review.  Make sure that tragedies are not the only reason inter-agency work is reviewed;
• have in place clear, systematic case recording and record keeping systems;
• develop good communication and mutual understanding between different disciplines and different Oxfordshire Safeguarding Children Board members;
• communicate with the local community and media to raise awareness of the positive and “helping” work of statutory services with children, so that attention is not focused disproportionately on tragedies;
• make sure staff and their representatives understand what can be expected in the event of a child death/ Serious Case Review.

There needs to be clarity over the interface between the different processes of investigation (including criminal investigations); case management, including help for abused children and immediate measures to ensure that other children are safe; and review, i.e. learning lessons from the case to reduce the chance of such events happening again.  The different processes should inform each other.  Any proposals for review should be agreed with those leading criminal investigations, to make sure that they do not prejudice possible criminal proceedings.

See also Allegations against Staff, Carers and Volunteers Procedure and Complex (Organised and Multiple) Abuse Procedure