Serious Case Reviews

1. Serious Case Reviews

2. Summary overview • Working Together (WT) 2006/09 • Ofsted grade descriptors • Bi-annual reviews • Ofsted annual reports • Regional analysis • Local findings

3. Working Together to Safeguard Children 2006/09 Key sections; Chapter 3 – Local Safeguarding Children Boards Sets out LSCBs role in ensuring the effectiveness of arrangements to improve outcomes for children, focusing on ‘stay safe’ Undertaking serious case reviews set out as a key part of monitoring the effectiveness of local arrangements Chapter 8 – Serious case reviews The procedures for undertaking SCRs Revised Dec 09 included in revision of WT 2010.

4. Criteria for SCR • When a child death (including by suspected suicide) AND abuse or neglect is known or suspected to be a factor in the death the LSCB should ALWAYS conduct a SCR • LSCB should consider conducting a SCR when a child is seriously hurt ………in the following situations

5. Child sustains potentially life threatening injury or serious and permanent impairment of physical/mental health and development through abuse or neglect, OR Child has been seriously harmed as result of being subjected to sexual abuse OR Parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004 OR A child has been seriously harmed following a violent assault by another child or adult AND ……… Situations to consider SCR

6. 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/or inter-disciplinary working

7. Chapter 8 – Serious case reviews • Purpose - learning lessons • Process • Terms of reference and scope • Timing • Independence • Individual management reviews (IMR) • Overview report • Executive summary • Action plan • Learning lessons

8. Roles in the process • LSCB - ensure the details of the case are scrutinised, instigate action plans to ensure lessons are learned • Each organisation - ensure that appropriate lessons are learned by the organisation and outcomes improve • Ofsted - evaluate whether the process has been followed and plans for children are robust and lessons are implemented. • GO/ SHA - offer support and challenge to the process to ensure learning is maximised • DCSF - ensure that Ministers are fully briefed issues are identified effectively and lessons are learned • Regulators - monitor whether lessons are acted on and learned by NHS organisations

9. Research and key publications • DCSF bi-annual reviews, since 2001 • Ofsted Annual Reports of SCRs since 2007 • Regional analysis, by GO • Local analysis, by LSCB

10. SCR gaps and tips • SCRs most effective when LSCBs have a culture of learning • Gaps: Overview reports do not provide enough information to understand why the child died or was seriously injured and the part services played. • Limited information about the family, e.g. • about parents’ past and ‘men’ • the family’s environment e.g. poverty • and the child. • Limited information about the agencies’ capacity and ‘climate’ • Tips: Scope the SCR for long enough to include past history, but include history in a ‘light touch’ chronology.

11. Summary of practice findings • Half are under 1 but older children are also vulnerable • Neglect and domestic violence are key factors • Substance/alcohol misuse and mental illness are also key factors • More than half of the children were known to children’s social care at the time of the incident • The absence of assessment of the impact of the learning difficulties of adults on their capacity as parents and on their own mental health • Communication between agencies is a frequent issue

12. IOW SCR 2008/9 • Main Issues • Communication between agencies • Failure in child protection processes • Neglect • Case drift • Thresholds to services • (SCR Process issues- Quality of IMRs, independence and timeliness)