6. Serious case reviews
6.1 Initiating a review
“When a child dies, and abuse or neglect is known or suspected to be a factor in the death….. the LSCB should always conduct a serious case review into the involvement with the child and family of organisations and professionals. Additionally, the LSCB should always consider whether a serious case review should be conducted where:
- a child sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or 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; or
- the case gives rise to concerns about inter-agency working to protect children from harm.
The purpose of serious case reviews… 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.
Serious case reviews are not inquiries into how a child died or who was culpable. That is a matter for Coroners and criminal courts……”
WSCB has established a Serious Case Review Panel who, at the request of the Board Chair, will consider whether the criteria above have been met and recommend whether a serious case review should be instigated, and if so, they will also consider and make recommendations as to the scope of the review and the terms of reference in accordance with the guidance provided within ‘Working Together’ which will include the timing, and which agencies should undertake management reviews. The Serious Case Review Panel, which is chaired by an independent person, will also consider whether to recommend section 47 enquiries be undertaken on any children who, on the basis of the information before them, they consider may be at risk.
The Child Death Overview Panel may also recommend concerns to the Serious Case Review Panel for consideration as to whether they feel a death meets the criteria outlined above.
6.2 The review process
Once a decision has been reached by the Serious Case Review Panel “that a case is being considered for review, each organisation should secure records relating to the case to guard against loss or interference.”
Management reviews will look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about in future.
On completion of each management review report, a senior officer will feedback and debrief the staff involved, in advance of the completion of the overview report by WSCB. This process may be repeated should the overview report raise new issues for the individuals or organisation.
While management reviews are not a part of any disciplinary process, disciplinary action may be indicated under established procedures. “In some case (e.g. alleged institutional abuse) disciplinary action may be needed urgently to safeguard and promote the welfare of children.”
6.3 Overview reports and implementation of recommendations
“The LSCB overview report should bring together, and draw overall conclusions from, the information and analysis contained in the individual management reviews, information from the child death review processes, and reports commissioned from any other relevant interests.”
On receiving the overview report, WSCB will:
- ensure the information is fully and fairly represented;
- turn the recommendations into an action plan, which will be signed by a senior person in each organisation, and set out who will do what, by when and with what intended outcome;
- set out how the outcomes in improvements to practice/systems will be monitored and reviewed;
- clarify to whom the report, or any part of it, should be made available;
- make arrangements to provide feedback to staff, family members of the subject child and media as appropriate; and
- provide a copy of the overview report to OFSTED and DCSF.
WSCB will make public the overview report’s executive summary, which will include information about the review process followed, the key issues arising and the recommendations that have been made.
