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All you need to know about Serious Case Reviews (SCRs) 

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A difficult subject 

This section explains why serious case reviews are carried out, who undertakes them and also what happens during and after the review process.

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When does a Serious Case Review (SCR) take place?
Who is responsible for setting up and conducting a serious case review?
What is the purpose of a SCR?
What happens during a serious case review?
What happens after the SCR?
A new approach

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When does a serious case reviews (SCR) take place?

There are some situations where an SCR should always be conducted. These are set out in the Government’s Working Together to Safeguard Children guidance (2010), Chapter 8, and include all situations when:

  • a child has died (including suicide), and abuse or neglect is known or suspected to have been a factor; or a child has died in custody, in a Youth Offending Institution or in a Secure Training Centre or secure children’s home; or
  • a child has died whilst being detained under the Mental Health Act 2005.

Working Together states that a SCR should also be considered when:

  • a child has suffered a potentially life-threatening injury or serious and permanent health or developmental impairment as a result of abuse or neglect; or
  • a child has been seriously harmed as a result of suffering sexual abuse; or
  • a parent has been murdered in an incident of domestic violence; or
  • a child has been seriously harmed in a violent assault by another child or an adult, 

and

‘ the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. This includes inter-agency and inter-disciplinary working’
Working Together para 8.11.

Any professional or agency who believes that the criteria for holding an SCR may have been met, may ask the LSCB to consider holding a SCR.
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Who is responsible for setting up and conducting a serious case review?

SCRs are conducted by the Local Safeguarding Children Board (LSCB) for the area in which the child is living, or, if the child has died, the area in which the child was normally resident. The decision to conduct a review is made by the LSCB Chair, and the matter then normally passes to the LSCB Sub-Committee responsible for SCRs. The Sub-Committee then sets up a SCR Panel to manage the review process. The Panel normally comprises representatives from the local authority children’s social care department, health and education services, the police and any other relevant agencies.

There are timescales attached to the SCR process, although they can be extended if necessary. The decision to conduct a review should be made within a month of the case coming to the attention of the Chair of the LSCB. The review itself should normally be completed within six months of the decision to conduct it.

Any incident serious enough to warrant consideration for a Serious Case Review (even if the eventual decision is not to hold one) should be brought to the attention of Ofsted by the local authority. Ofsted should also be informed of the decision on whether or not to conduct a review.
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What is the purpose of a SCR?

The point of the Serious Case Review is not to name and blame individuals or agencies, but rather to look at where improvements in practice need to be made in order to limit the risks to other children and young people. 

Working Together (2010) breaks down the purpose of the Serious Case Review into three headings (para 8.5):

  • 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, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and 
  • Improve intra- and inter-agency working and better safeguard and promote the welfare of children.

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What happens during a serious case review?

There are a number of stages in the progress of a SCR. Here they are summarised in brief:

1. Drawing up terms of reference

The SCR Sub-Committee examines the information that is available about the case and considers the scope of the review, drawing up terms of reference that are sent to the LSCB Chair for approval. Working Together (2010) sets out some of the issues to consider in (para 8.20). They include identifying the important issues to be addressed; how the child (in cases where the review does not involve a death) and members of the child’s family might contribute; considerations around diversity and equality; which organisations and professionals should be asked to contribute; how the review can be conducted alongside other processes that might be happening such as legal proceedings.

At this stage, the Sub-Committee should also make a decision as to who should be appointed as the independent author of the overview report, which pulls together and analyses all the information gathered during the course of the SCR.
 
2. Individual Management Reviews (IMR)

For lessons to be learnt when a child has died or been seriously injured, the LSCB needs information about how relevant organisations and professionals have each dealt with the child and their family. This information is collected in a standardised format called an ‘Individual Management Review’ (IMR). A separate IMR is normally prepared by or on behalf of each organisation asked to submit one. 

Chapter 8 of Working Together outlines what should be covered in an IMR report (paras 8.34 – 8.39). It includes a chronology of the organisation’s involvement with the child and family, an analysis of that involvement, lessons learnt and recommendations for action.

The SCR panel will reach a judgement about the degree and significance of involvement by the agency with the child and their family to decide whether an IMR is required from that agency or organisation. The terms of reference will need to be very specific about which agencies are involved and the contribution they will be expected to make. The LSCB chair should notify the chief officer of each organisation of the SCR and specify exactly what is required of their organisation with clear timescales and templates.

Most of the key agencies represented on LSCBs will have designated officers who are responsible for undertaking IMRs. The IMR author should have had no involvement with the case, and should not have been the immediate line manager of the practitioners involved. This officer should be supervised by a manager who should also have had no direct responsibilities for the case. Their independence from the case must be explicit, and clearly recorded within the IMR and SCR.

The officer preparing the IMR should be someone at a senior enough level to carry authority and be competent in undertaking the review. If it is not possible to find someone from within the agency who fulfils these criteria, then the SCR Panel may choose to commission an external person to undertake the IMR. This could be through a reciprocal arrangement with a similar organisation in another local authority.

Organisations with less experience of conducting IMRs, for example from the voluntary and community sector, may need support and advice from the LSCB with producing an IMR, and the SCR panel should ensure this is identified and provided.

3. The Serious Case Review overview report

This overview report is produced by the independent person identified by the SCR Sub-Committee early in the proceedings. It should bring together all the information gathered in the IMRs, from the child death review process (if the child has died), and from any other reports or contributions that have been requested. The overview report goes on to analyse the information that has been submitted and to set out conclusions and recommendations.

The SCR Panel is responsible for ensuring that the review process is actively managed and that the individual organisations and professionals feel that their information is represented fairly and accurately in the overview report.

4. The action plan

The SCR Panel is required to produce an action plan from the recommendations of the overview report. The sets out who will do what and the timescales involved. It also stipulates outcome measurements, and processes for reviewing and monitoring the implementation of any changes that have been recommended. The action plan should be signed up to by senior managers in each of the organisations responsible for implementing the recommendations of the review.

5. The executive summary

This summary should summarise the facts and the key issues, setting out priorities for learning and change and reproducing the recommendations and action plan.

6. Approving and publishing the SCR report

The final SCR, action plan and executive summary have to be approved by the LSCB. Once approved, both SCR overview reports and executive summaries  have to be made available to the public in a form which protects the identity of children, family members and other individuals involved (including professionals). Prior to June 2010, only the executive summaries were published but this has now changed.

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What happens after the SCR?

A number of actions are outlined in Working Together (2010) (paras 8.41, 8.44-8.56):

  • Feedback and support must be given to the child (if the child is still living), family members and others associated with the case
  • Copies of the SCR reports, including IMRs, should sent to Ofsted
  • The implementation of the action plan should be monitored and reviewed by the LSCB
  • Once the action plan has been implemented, the LSCB should formally close the review process

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A new approach

The Social Care Institute for Excellence (SCIE) has developed a multi-agency systems model for use in the process of conducting serious case reviews. Entitled Learning Together, it has been recommended by Professor Eileen Munro in her review of the child protection system published in May 2011. Professor Munro states in Recommendation 9 of her review that:

‘The Government should require LSCBs to use systems methodology when undertaking Serious Case Reviews (SCRs)’
(Munro, Eileen (2011) The Munro review of child protection: final report; a child-centred system. The Stationery Office.

The Government has since made it clear in its reponse in July 2011 to Professor Munro’s review, that agrees with this recommendation and that systems methodology should be used by LSCBs in their review processes.

The new approach is being used increasingly across the country. Watch out for more information on how it is impacting on the voluntary and community sector, and on how the VCS can make useful contributions to serious case reviews if called upon to do so. 
 
Some important points about the SCIE Learning Together approach

  • It helps to identify which factors in the work environment support good practice and which create unsafe conditions in which poor safeguarding practice is more likely.
  • It has been adapted from the systems approach used in other high risk areas of work, such as aviation and health.
  • It helps to produce an analysis that goes beyond identifying what happened to explain why it happened.
  • It recognizes that actions or decisions will usually have seemed sensible at the time they were done or taken.
  • It moves beyond the basic facts of a case to appreciating the views of people from different agencies and professions.
  • It takes a collaborative approach – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.
  • It recognizes that any worker’s performance is a result of both their own skill and knowledge and the organisational setting in which they are working.
  • It suggests that the aim of any change in the system and in working practices following a review should ‘make it harder for people to do something wrong and easier for them to do it right’.
    Taken from: At a glance 01: Learning together to safeguard children: a systems model for case reviews. SCIE January 2012

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