12.1 Learning and Improvement (Including Serious Case Reviews)
SCOPE OF THIS CHAPTER
This chapter covers the requirements within chapter 4 of Working Together to Safeguard Children 2015, which describes the way that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. It explains the requirements for an integrated local learning and improvement framework and the principles to be used when undertaking Serious Case Reviews, as well as other forms of reviews and audits.
Working Together 2015 requires that the Local Safeguarding Children Board maintain a shared local learning and improvement framework across those local organisations working with children and families.
This local framework covers the full range of single and multi-agency reviews and audits which aim to drive improvements to safeguard and promote the welfare of children. The different types of review include:
- Serious Case Review (see Section 2, Serious Case Review Process);
- Child death review (see Working Together to Safeguard Children: 2015, Chapter 5 Child Death Reviews: a review of all child deaths under the age of 18);
- Review of a child protection incident which falls below the threshold for a Serious Case Review;
- Review or audit of practice in one or more agencies.
The aim of this framework is to enable local organisations to improve services through being clear about their responsibilities to learn from experience and particularly through the provision of insights into the way organisations work together to safeguard and protect the welfare of children.
This should be achieved though:
- Reviews conducted regularly;
- Such reviews to encompass both those cases which meet statutory criteria (i.e. Serious Case Reviews and child death reviews) and cases which may provide useful insights into the way organisations are working together to safeguard and protect the welfare of children;
- Reviews examining what happened in the case, why it did so and what action will be taken to learn from the findings;
- Learning from both good and more problematic practice about the organisational strengths and weaknesses within local services to safeguard children;
- Implementation of actions arising from the findings which result in lasting improvements to services;
- Transparency about the issues arising and the resulting actions organisations take in response to the findings from individual cases, including sharing the final reports of Serious Case Reviews with the public.
Reviews are not an end in themselves, but a method to identify improvements needed and to consolidate good practice. The LSCB and partner organisations will translate the findings from reviews into programmes of action which lead to sustainable improvements.
There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, so as to identify what works and what promotes good practice.
Within this culture the principles are:
- A proportionate response: according to the scale and level of complexity of the issues being examined i.e. the scale of the review is not determined by whether or not the circumstances meet statutory criteria;
- Independence: Reviews of serious cases to be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
- Involvement of practitioners and clinicians: Professionals should be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
- Offer of family involvement: Families, including surviving children, should be invited to contribute to reviews and be provided with an understanding of how this will occur;
- The child to be at the centre of the process;
- Transparency achieved by publication of the final reports of Serious Case Reviews and the LSCB’s response to the findings. The LSCB annual reports will explain the impact of Serious Case Reviews and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children. This will also inform inspections;
- Sustainability: improvement must be sustained through regular monitoring and follow-up so that the findings from these reviews make a real impact on improving outcomes for children.
The LSCB must undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 set out the LSCB’s function in undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.
A Serious Case Review must always be initiated when:
- Abuse or Neglect of a child is known or suspected; AND
- The child has died; OR
- 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.
Thus cases meeting either of these criteria must always trigger a Serious Case Review:
- Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
- Abuse or Neglect of a child is known or suspected AND 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. In this situation, unless it is clear that there are no concerns about inter-agency working, a Serious Case Review must be commissioned.
Additionally, even if these criteria are not met a Serious Case Review 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.
The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 2.1, Criteria) for a Serious Case Review. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).
The LSCB must notify Ofsted and the National Panel of Independent Experts of the decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the LSCB chair may be asked to give evidence in person to the panel.
If the Serious Case Review criteria are not met, the LSCB may still decide to commission a Serious Case Review or an alternative form of case review.
Working Together to Safeguard Children 2015 announced a plan for a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews to be implemented during 2013/14. The panel will report to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel’s advice on:
- Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
- Appointment of reviewers;
- Publication of Serious Case Review reports.
LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.
Working Together 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:
- Recognises the complex circumstances in which professionals work together to safeguard children;
- Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
- Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
- Transparency about the way data is collected and analysed; and
- Makes use of relevant research and case evidence to inform the findings.
Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.
2.4.1 Some Examples of Models which may be considered
- SCIE Learning Together* (LT) has been piloted and evaluated during the Working Together consultation period** and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved.
- Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened.***
- Child Practice Reviews **** replaced the Serious Case Review system as the statutory guidance in Wales on 01.01.13, This process consists of several inter-related parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an Extended review which involves an additional level of scrutiny of the work of the statutory agencies.
- Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’.
- Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR’s conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong. They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.
Serious case Reviews are not limited to systems methodology; there may be cases which require the inclusion of issues from outside a strictly defined systems model.
* Fish, S., E. Munro, and S. Bairstow, Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 2008, Social Care Institute for Excellence: London)
** Undertaking Serious Case Reviews using the Social Care Institute for Excellence (SCIE) Learning Together systems model: lessons from the pilots. March 2013
*** Root Cause Analysis (RCA) Investigation website
**** Protecting Children in Wales. Guidance for Arrangements for Multi-Agency Child Practice Reviews. 2013
Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Section 1.2, Purpose of Local Framework, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.
The LSCB will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews using the Section 1.3, Principles for a Culture of Continuous Improvement.
The lead reviewer should be independent of the LSCB and the organisations involved in the case.
The LSCB will provide the National Panel of Independent Experts (see Section 2.3, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.
Working Together 2015 does not specify the need for an independent chair, or for a chair for the process: the need or not for this will depend on the individual choice of the LSCB and the review model selected.
The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:
- Capture points from the case about improvements needed; and
- Take any corrective action identified as required.
The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.
The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.
The LSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings.
In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.
The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.
The final Serious Case Review report should:
- Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
- Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
- Be suitable for publication without needing to be amended or redacted.
The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:
- Actions already taken in response to the review findings;
- The impact these actions have had on improving services; and
- What more will be done.
The LSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, it should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.
- Engagement of families, children and service users;
- Engagement of frontline professionals involved in the case;
- Coordination with parallel review processes (such as Domestic Homicide Reviews);
- Publication in full of the Overview Report;
- Appointment of a “lead reviewer” rather than an Overview author and independent chair;
- Auditing and monitoring of the ‘programme of action’ following the findings of the review;
- Holding Heads to Agencies to account and engaging them with the dissemination of lessons learned and redressing system failures.
The NSCB’s Learning & Improvement Framework incorporates lessons from reviews and audits, data and feedback from safeguarding service users. This document along with detailed SCR processes will be published on the NSCB website and reviewed regularly.