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9.1 Learning and Improvement Including Serious Case Reviews


Contents

  1. Introduction
  2. Purpose of the Local Framework
  3. Principles for Learning and Improvement
  4. Governance of Learning and Improvement Framework
  5. Serious Case Reviews (SCRs)
  6. Critical Incident Reviews (CIRs)
  7. Role of the Performance Committee
  8. Role of the Serious Case Review Committee
  9. Impact Measures and Evaluation of Learning
  10. Significant Practice Events Chronologies
  11. Sharing Learning
  12. Implementation
  13. North West Learning & Improvement Framework Case Review Methodologies
  14. Proportionate Approach to Serious Case Reviews

    Appendix A: SCR Referral Form

    Appendix B: Decision Making Matrix for SCR's

    Appendix C: Case Review Threshold Flowchart

    Appendix D: Examples of Review Models

    Appendix E: WSCB Learning Summary Template

    Appendix F: SCR Flowchart 1 SCR/CIR Review Process

    Appendix G: Terms of Reference for Performance Committee

    Appendix H: Terms of Reference for SCR Committee

    Appendix I: Template for Significant Practice Event Chronologies


1. Introduction

Working Together to Safeguard Children (2015) requires all LSCBs to maintain a local Learning and Improvement Framework. The framework should collate the findings and lessons from the full range of case reviews (from statutory Serious Case Reviews and child death reviews, to case reviews below the thresholds of a serious case review), audits and practitioner forums.

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 and young people in Wirral.


2. Purpose of the Local Framework

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 through:

  • 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 WSCB and partner organisations will translate the findings from reviews into programmes of action which lead to sustainable improvements.

The development of this Learning and Improvement Framework enables the Wirral Safeguarding Children Board (WSCB), its partner organisations and local partnership bodies to be clear about what needs to be learnt, where services and practice require improvement, and how any programme of action will lead to sustainable improvements. Reviews of individual cases, or an audit on a number of cases, can also be selected for the ‘good’ outcomes, to help identify learning, disseminate the learning and embed into practice the characteristics of practice that lead to good outcomes for children and their families.


3. Principles for Learning and Improvement

The following principles have been adapted from the English[1] and Welsh[2] statutory guidance. Statutory guidance documents outline both methodological and outcome principles in one set, but for ease of use and clarity the principles below are separated.

Principles in the Methodology

The WSCB presents the following principles to outline the statutory requirements that it adheres to in methodology and processes used to conduct the different case reviews, practitioner forums and audits. The principles play a vital part in shaping the design and development of our arrangements.

  • There should be a culture of continuous learning and improvement across organisations, identifying opportunities to draw on what works and promote good and effective multi-agency practice;
  • Case reviews, practitioner forums and audits should provide regular opportunities to address multi-agency collaboration and practice through learning, reflection and development;
  • Learning and reviewing methods recognise the complex circumstances in which professionals work together to safeguard children – as much effort in the process of reviewing should go into identifying and analysing areas of good practice as well as practice that requires improvement;
  • Learning and reviewing methods are transparent in the way they collate and analyse data and make use of research and evidence to inform findings;
  • Case reviews, practitioner forums and audits must seek to understand precisely who did what and the underlying reasons that led individuals, teams and organisations to act as they did/do;
  • The approach taken on learning and reviewing should be proportionate to the scale and complexity of the issues being examined;
  • Professionals must be involved in learning and reviewing opportunities; contributing their perspectives without a fear of being blamed for actions taken in good faith;
  • Families, including children (where possible) should be invited to contribute in learning and reviewing opportunities; there should be clarity of how they will be involved and their expectations should be managed appropriately and sensitively;
  • Serious Case Reviews should be led by one or more persons who are independent of the case being reviewed and the organisations whose actions are being reviewed;
  • There is transparency with professionals, family and the public in disseminating the learning; final serious case review reports will be published[3] and findings from all other reviews, practitioner forums and audits will be summarised in the WSCB annual report.

Outcome Principles

The following principles outline the outcomes WSCB and its partner agencies aim to achieve through the process of conducting case reviews, practitioner forums and audits. These outcomes are always be placed in the context that any system, including safeguarding systems can only manage and reduce risk, not eliminate it and that systems are made up of numerous variables that constantly change and fully appraising and managing risks of each variable is a complex task.

  • Learning and reviewing opportunities should be transparent so that they identify promptly the need for systemic or organisational changes and ensures timely action is taken;
  • Professionals in all services working with children and families are given the assistance they need so that they can undertake the complex and difficult work of protecting children with confidence and competence;
  • Organisational and multi-agency cultures, and the processes that underpin the cultures, are experienced as fair and just by professionals, and promote supportive work and management environments for them;
  • Through regular monitoring and follow up, improvements recommended and actions from findings must be sustained;
  • Transparency is created that shares and disseminates lessons learnt on a multi-agency basis locally, regionally and nationally;
  • The processes used for learning, the findings from reviews and action taken should provide accountability and reassurance to children, families, the public and government/inspectorates;
  • The impact of case reviews, practitioner forums and audits should be to improve services for children and families and on reducing the incidence of harm; the impact of Serious Case Reviews should be to reduce the incidence of serious harm and death in children.

[1] Working Together to Safeguard Children, DfE (2015)
[2] Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government (2012)
[3] In line with the directions from the Minister for Children and Families, 24.06.2013


4. Governance of Learning and Improvement Framework

The Framework establishes the model and processes for undertaking reviews from the most serious case reviews to single agency audits where learning is available and improvements to practice and outcomes for children, young people and families can be realised.

Responsibility for ensuring the functioning of the framework lies with the WSCB Performance Committee. This responsibility includes:

  • Liaison with the Chair of the SCR Committee and the WSCB Independent Chair where notification is received that a case may have reached the threshold for a SCR;
  • Undertaking of multi-agency audits and single agency audits;
  • Monitoring of multi-agency and single agency SCR/CIR action plans, and holding agencies to account for progress against actions;
  • Liaising with the Learning and Development Committee to determine and disseminate learning;
  • Reporting on SCR and CIR case process and action plan progress to the WSCB Executive.

Learning and Improvement Framework

The following diagram represents the components and their interrelationships of the framework the WSCB will use to conduct the different types of multi-agency case reviews, practitioner forums and audits.

Click here to view the Learning and Improvement Framework Flowchart.


5. Serious Case Reviews (SCRs)

Referring a Case for Serious Case Review Consideration

Any professional can refer a case to the WSCB for consideration for a Serious Case Review where a child has died or been seriously harmed and they have concerns about the way that agencies have worked together to safeguard and promote their welfare; this includes the Merseyside Child Death Overview Panel.

Professionals should discuss any potential case with the lead/senior safeguarding manager for safeguarding within their organisation before a referral is made. Referrals to the WSCB should be made by the lead/senior safeguarding manager.

Referrals should be made to the WSCB SCR Committee using the WSCB’s secure email address (wscb@wirral.gscx.gov.uk) on the form included in Appendix A: SCR Referral Form. The received form will be copied to the WSCB Business Manager (who will notify the WSCB Independent Chair and the Director of Children’s Services).

Arrangements will then be made for a multi-agency group to consider the circumstances of the case and decide whether the criteria for a Serious Case Review are met (and if not, whether an alternative review should be carried out). The Chair of the WSCB Serious Case Review Sub Group will provide written feedback to the referrer on the outcome of the multi-agency discussion and the rationale for the decision. The decision whether to undertake a SCR, or other review will be informed by use of the decision making matrix (Appendix B: Decision Making Matrix for SCR's). The WSCB Business Manager will keep the WSCB Independent Chair and Director of Children’s Services informed throughout the process.

Initiation of Case Reviews

The WSCB will determine the most suitable process to use in deciding if a case meets the criteria for a case review, or nominating areas/safeguarding themes for practitioner forums/case file audits. This determination will be made by the Serious Case Review sub group, led by the Chair.

For cases that are considered for serious case reviews, the final decision if a case meets the serious case review criteria (as judged by the Serious Case Review Committee) will rest with the WSCB’s Independent Chair. Decisions on whether to initiate a serious case review will normally made within one month of the WSCB being notified of the incident triggering the threshold.

In line with the directions issued by the Children and Families Minister[4], the National Panel of Independent Experts on serious case reviews will be notified within 14 days of the WSCB Chair’s decision on whether a serious case review is to be initiated. Where a case is considered for a serious case review and the WSCB Chair decides the threshold is not met, additional information to justify the decision will be required to be provided to the National Panel of Independent Experts on serious case reviews. Where the notification to the National Panel of Independent Experts on serious case reviews is to initiate a serious case review, the notification information should also contain the name(s) of the independent Lead Reviewer(s) appointed by the WSCB Chair.

National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children 2013 introduced a plan for a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews.  The panel reports 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.

In cases where the LSCB Chair has decided NOT to initiate a SCR, the Chair should:

  • Inform the panel within 14 days and provide a copy of the local authority’s Serious Incident Notification (or if this is not available then brief anonymised details of the case covering the nature of the incident etc);
  • Provide an explanation why the case does not meet the SCR criteria.

The panel is initially hosted in the Department of Education and can be contacted via Mailbox.SCRPANEL@education.gov.uk.

Case Review Methodologies

All LSCBs must conduct SCRs in line with requirements in paragraphs 12 to 18 and the checklist on pages 70 to 72 of Chapter 4, Working Together to Safeguard Children (2013). In the next section, the methodology recommended by the North West Safeguarding Steering Group is outlined and to ensure consistency for all stakeholders in the process, it is proposed that LSCBs use the methodology[5] including the use of proportionate methodologies between complex and less complex cases.

Whilst Working Together 2013 stops short of advocating any specific method for undertaking a SCR, the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as a model consistent with the five stated principles.

The WSCB will consider the most appropriate methodology on a case by case basis and this will include either the methodology developed and recommended by the North West Safeguarding Steering Group or one of the other methodologies commonly used by LSCB’s which are summarised in Appendix D: Examples of Review Models.

Appointing Reviewers

The WSCB 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 principles for learning and improvement set out in Section 3, Principles for Learning and Improvement.

The lead reviewer should be independent of the WSCB and the organisations involved in the case.

The WSCB will provide the National Panel of Independent Experts 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 WSCB and the review model selected.

Timescale for Completion of the SCR

The WSCB 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.

Engagement of Organisations

The WSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

The WSCB 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.

Agreeing Improvement Action

The WSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings. Progress against actions will be reported into the Performance Committee on a quarterly basis and the committee will hold organisations to account for progress on behalf of the WSCB.

Publication of Reports

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 WSCBs 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 WSCB 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 WSCB 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 WSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the WSCB considers that a report should not be published, it should inform the panel which will provide advice. The WSCB will provide all relevant information to the panel on request, to inform its deliberations.

[4] Letter from the Children and Families Minister, Edward Timpson to LSCB Chairs, Directors of Children’s Services, Local Authority Chief Executives and Lead Member, DfE, 24.06.2013
[5] LSCBs are requested that any departure from the methodology, where new methodologies are trialed, is brought to the attention of the North West Safeguarding Steering Group to consider if revision to this framework is required


6. Critical Incident Reviews (CIRs)

Critical Incident Reviews (CIR’s) are reviews of all cases falling below the SCR threshold. Cases can involve incidents where a child has been harmed and there are concerns about multi-agency practice, or involve incidents where multi-agency practice is considered to be good (after a child has been harmed or where a child has been prevented from being harmed) and agencies seek to identify the characteristics and enablers of that good multi-agency practice.

The WSCB applies the following criteria to follow in selecting cases for a critical incident review:

  • Cases considered for a SCR which did not meet the criteria will automatically be considered for a CIR;
  • A child is harmed through abuse/neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard the child that could lead to significant and new learning that improves multi-agency communication, procedures, policy and/or practice.

Where a case gives rise to concern about learning already identified in previous case reviews, practitioner forums or case audits, the WSCB will review, outside of the multi-agency concise review process, how that learning is being embedded and query why the learning has not been sustained.

Individual Agency Reviews

Where a case is considered for a SCR or CIR but does not meet the criteria, as practice requiring further analysis and learning is limited to a single agency, the SCR Committee may recommend an Individual Agency Review. The methodology used to undertake a review and how the lessons will be disseminated will be decided by the SCR Committee.

Performance Committee Multi-Agency Professional Discussion Forums

The Performance Committee will establish regular forums for practitioners to discuss practice so that they can safely and openly consider, challenge and change multi-agency practice. The Performance Committee, the wider Board and sub groups or any professionals through their agency can identify themes, including as outlined in the diagram above where findings from different review processes identifies the need to change practice.

Equally, changes in national guidance, identification of best practice principles, concerns with the effectiveness of a policy/procedure, or a timetabled review of a policy/procedure could also be reasons for convening a forum.

The Performance Committee will select the appropriate method of undertaking practitioner forums that suit their local practitioners and the theme being discussed.

Disseminating Identified Learning

Upon completion of a review, the Learning Summary Template (Appendix E: WSCB Learning Summary Template) will be completed. This will summarise the range and type of learning identified through the review.

This will be presented to both the WSCB Performance and Learning and Development Committees. The performance Committee will also be responsible for sharing identified learning with the WSCB Executive.


7. Role of the Performance Committee

This framework will apply to the WSCB and all partner agencies in their delivery of workforce development activities. It should also inform single agency frameworks to ensure connectivity and compatibility. It is also therefore essential that the members of the WSCB Performance Committee. Membership is established in the Terms of Reference (Appendix G: Terms of Reference for Performance Committee).

The Performance Committee meets every six weeks and consideration of a case will be placed on the agenda for the next meeting following completion of a local review and submission of a Learning Outcomes Summary sheet to the committee. An action plan will be developed which will identify the relevant actions needed across agencies in order to ensure that any learning following review is disseminated effectively.

The learning and recommendations identified following review can be implemented in a number of ways, such as improved procedures and policies (through the PPP committee), supported through training programmes (through the Learning and Development Committee) and in other relevant learning activities. In some cases it will be incumbent on individual agencies to consider how these recommendations can best be implemented and in turn provide assurance to the WSCB that this has been achieved effectively.

Completed action plans will be reviewed and the impact measures collated at the regular meetings. Agencies responsible for individual action plans will be required to present quarterly updates on progress to the performance Committee by exception reporting. The Performance Committee will provide the WSCB Executive with a summary report and highlight any outstanding items.

Key messages identified at review will also be integrated within WSCB Multi Agency training (through the Learning and Development Committee).


8. Role of the Serious Case Review Committee

The Serious Case Review Committee makes recommendations to the WSCB Chair on the need for SCRs. They are responsible for overseeing the production, publication and quality assurance of SCRs and CIR’s. If a SCR is agreed by the Independent Chair, the committee will act as the SCR panel which will be composed up of core members of the Committee as well as Quality Assurance senior officers from the agencies involved.

Upon approval of the SCR or CIR Overview report the SCR committee will translate the recommendation into desired outcomes for identified agencies. The committee will require agencies to develop actions and once approved by the committee responsibility for oversight of the action plan will be passed to the Performance Committee.

A complete Terms of Reference for the SCR Committee is included in Appendix H: Terms of Reference for SCR Committee.


9. Impact Measures and Evaluation of Learning

Each action plan will identify the actions required to effectively share the lessons to be learnt from review. It will also include a series of impact measures which will be reviewed once the work has been completed.

The committee will evaluate the impact of actions completed and identify how these actions have contributed towards improving the outcomes for children and their families.

Consistent with recommendations of Professor Eileen Munro, this framework outlines a systems approach to case review. A proportionate approach of Intensive and Targeted reviews is proposed. A flowchart to support decision making is at Appendix B: Decision Making Matrix for SCR's. These methodologies are based on practical experience of a range of systems approaches to case reviews within the North West across children’s and adult services. They focus on the discharge of Local Safeguarding Children Boards’ responsibilities to undertake reviews of serious cases as confirmed below.

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:

  • 5 (1) (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned;
  • (2) For the purposes of paragraph (1) (e) a serious case is one where:
    1. Abuse or neglect of a child is known or suspected; and
    2. Either — (i) the child has died; or (ii) 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.


10. Significant Practice Events Chronologies

There is a strong commitment that robust and proportionate chronologies inform decisions to initiate case reviews and determine the scope and methodology for review. Each relevant agency will provide ‘Significant Practice Event’ chronologies to detail its involvement with the child who is the subject of the review. A template for the completion of the SPE chronologies is included in Appendix I: Template for Significant Practice Event Chronologies. Whilst this framework embraces the value of local approaches to chronologies, a robust and consistent approach focussed on the following principles should be considered:

  • Risk: Each Significant Practice Event (SPE) details the presentation of risk;
  • Response: Agency response is clear;
  • Partnership: Understanding of multi-agency considerations is apparent;
  • Learning: The core of the methodology and chronologies should identify learning opportunities, in particular those which are significant or new.

Defining Significant Practice Events

The use of Significant Practice Events (SPE) chronologies is integral to ensure clear parameters of any review are agreed based upon the circumstances of the case. They will be used to support decision making on whether Serious Case Review criteria have satisfied; how case reviews can be discharged in a proportionate way; and how engagement with Case Groups should be configured. Agencies should consider the following when preparing SPE chronologies:

  • Is this event one that changed/could have changed your assessment of the situation for the child?
  • Is this event symbolic or indicative of a pattern of events that individually would not otherwise be considered significant?
  • Is this a ‘statutory’ event e.g. child protection conference, court hearing or similar?
  • Would this have been an event that the child perceived as significant in their life?
  • Would this have been an event that a significant adult would perceive as significant in their life or the life of the child?
  • Has this event got significance as a learning point for agencies?

Intensive Serious Case Review

Where cases are of a very serious and/or very complex nature, the WSCB will consider undertaking an Intensive Serious Case Review. On an exceptional basis there may be learning benefits from adopting the Intensive Serious Case Review approach in less complex cases.

Targeted Serious Case Review

This methodology seeks to target review activity in a proportionate way based on the specific circumstances of the case. A Targeted Case Review should be considered in the following circumstances

  1. Serious Case Reviews where 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 and the LSCB considers that criteria under Regulation 5(2)(a) have not been met;
  2. Serious Case Reviews where the WSCB considers it is proportionate to use the Targeted Case Review methodology. This may include cases where:
    1. Chronologies reveal SPEs are limited in scope and it would not be compatible with the principles of Working Together in respect of proportionality to undertake an Intensive Case Review;
    2. The scope for learning is focused on an area of practice, or issues which have already been recently identified and agencies are in the process of, or recently implemented a programme of action;
    3. In exceptional circumstances, if the case is largely historical in nature and it is not practicable or desirable to undertake an Intensive Case Review; or
    4. The WSCB Chair does not consider the Serious Case Review threshold to have been met, but peer challenge or consultation with the National Panel of independent experts on Serious Case Reviews would suggest that initiation of a Serious Case Review may be prudent.

Critical Incident Reviews

Where the WSCB considers the criteria for a multi-agency Critical Incident Review is met, the WSCB will decide the most appropriate methodology for conducting the review, ensuring all the appropriate methodological and outcome principles are met.

Review Group

The Review Group should be made up of senior managers from relevant agencies and qualified Lead Reviewers who are independent of the case. In Intensive Serious Case Reviews and Targeted Serious Case Reviews where the statutory threshold for initiation of an SCR has been satisfied, Lead Reviewer(s) should be fully independent of all the agencies of the WSCB.

Where the WSCB chooses to conduct other types of reviews like Critical Incident Reviews, internal Lead Reviewers may be appointed as appropriate.

Case Group

The Case Group will be made up of the frontline practitioners and managers who were involved in the case, especially those involved in the Significant Practice Events. Case Group members can individually contribute to the case review, or different agency practitioners brought together in forums. The aim is to understand the practitioner’s view of the practice events (source of data) and assist in analysing ‘contributory factors’ and how the safeguarding system can be improved.

The involvement of practitioners in the case review must be a safe way for them to contribute to identify the learning, and empower them to share and disseminate the learning. Case Group members must be informed and consulted on the findings from the case review and provided the opportunity to help the Review Group in correcting and enhancing the findings and learning.


11. Sharing Learning

Integral to the success of this framework will be the sharing of learning on a wide area basis to ensure transparency, accountability and consistent improvement to practice. As such, in addition to the statutory requirements on publication, North West LSCBs will seek to develop mechanisms to share, where practicable, the outcomes of case reviews and multi-professional discussion forums which do not meet Serious Case Review thresholds. In addition, there will be an expectation placed upon Lead Reviewers, via commissioning arrangements or other means, that concise Learning Summary documentation will form part of all review reports. A template for this is proposed at Appendix E: WSCB Learning Summary Template.

The North West LSCB Business Manager’s Group will collate the learning summaries on a periodic basis to analyse and disseminate the learning from across the region. Periodically the group will also evaluate how this framework is working and advise the North West Safeguarding Steering Group of any changes required to this framework.


12. Implementation

This framework is intended as a first stage of development of a North West approach to learning and improvement. A period of consultation and reflection should be undertaken in order to ensure the Framework is implemented successfully, with consideration of the following issues of particular importance:

  • Developing a Systems Approach: It is acknowledged that the systems approach to case review is underdeveloped in many areas. Some LSCB partners have experiences of methodologies such as Root Cause Analysis (RCA) they may wish to test against these methodologies;
  • Typology of Learning Characteristics: In order to facilitate consistent sharing of learning on a local, regional and national basis, implementation will need to fully consider the agreement of a shared typology of learning characteristics;
  • Training: In addition to identification of a series of training needs and appropriate provision to meet those needs, the early implementation of any systems approach will need to create conditions for learning of itself. Accessing Department for Education funded training delivered via the NSPCC, in partnership with Action for Children and Sequeli Ltd on 'Improving the Quality of Children's Serious Case Reviews' will form a constituent element of this[6].

[6] Funding and commissioning of national training by the DfE may alter; LSCBs are advised to contact the DfE to ascertain most up to date accredited training.


13. North West Learning & Improvement Framework Case Review Methodologies

(Developed by North West Safeguarding steering group July 2013).

Consistent with recommendations of Professor Eileen Munro, this framework outlines a systems approach to case review. A proportionate approach of Intensive and Targeted reviews is proposed. A flowchart to support decision making is at Appendix B: Decision Making Matrix for SCR's. These methodologies are based on practical experience of a range of systems approaches to case reviews within the North West across children’s and adult services. They focus on the discharge of Local Safeguarding Children Boards’ responsibilities to undertake reviews of serious cases as confirmed below.

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:

  • 5 (1) (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned;
  • (2) For the purposes of paragraph (1) (e) a serious case is one where:
    1. Abuse or neglect of a child is known or suspected; and
    2. Either — (i) the child has died; or (ii) 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.

Significant Practice Events Chronologies

There is a strong commitment that robust and proportionate chronologies inform decisions to initiate case reviews and determine the scope and methodology for review. Each relevant agency will provide ‘Significant Practice Event’ chronologies to detail its involvement with the child who is the subject of the review. It is recommended that, to ensure consistency, organisations use the Chronolator software employed by the WSCB. A robust and consistent approach to SPE’s focussed on the following principles should be considered:

  • Risk: Each Significant Practice Event (SPE) details the presentation of risk;
  • Response: Agency response is clear;
  • Partnership: Understanding of multi-agency considerations is apparent;
  • Learning: The core of the methodology and chronologies should identify learning opportunities, in particular those which are significant or new.


14. Proportionate Approach to Serious Case Reviews

The following table outlines the staged approached to Intensive and Targeted Serious Case Reviews[7]. Specific attention is drawn to emphasis upon the process of analysis at the heart of the review.

Click here to view the Proportionate Approach to Serious Case Reviews table.

[7] Adapted from the Social Care Institute of Excellence (SCIE) Systems Methodology


Appendix A: SCR Referral Form

Click here to view the SCR Referral Form.


Appendix B: Decision Making Matrix for SCR’s

Click here to view the Decision Making Matrix for SCR's Form.


Appendix C: Case Review Threshold Flowchart

Click here to view the Case Review Threshold Flowchart.


Appendix D: Examples of Review Models

  • 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.

Irrespective of the methodology the emphasis must be on undertaking an appropriate review which is proportionate to the scale and level of complexity of the issues being examined.

* 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


Appendix E: WSCB Learning Summary Template

Click here to view the WSCB Learning Summary Template Form.


Appendix F: SCR/CIR Review Process

Click here to view the SCR/CIR Review Process Flowchart.

Click here to view the SCR Action Planning and Monitoring Flowchart.


Appendix G: Terms of Reference for Performance Committee

Performance Committee

Terms of Reference

  1. To undertake quality assurance and audits of inter-agency safeguarding practice and management of standards;
  2. To develop the WSCB Learning and Performance framework and be responsible for implementation;
  3. To develop a multi-agency audit framework to undertake audits that has clear and measurable outcomes;
  4. Establish a common audit approach for both case audits and auditing of the implementation of policy and procedures;
  5. To be responsible for monitoring progress against multi and single agency action plans arising from Serious Case Reviews, Critical Incident Reviews, and other audits;
  6. To monitor and report on the implementation of inter-agency procedures and processes;
  7. To report to the WSCB Executive via the Chair on matters relating to agencies’ performance;
  8. To establish multi-agency professional discussion forums for practitioners to discuss practice so that they can safely and openly consider, challenge and change multi-agency practice;
  9. To establish a formal work plan that commits agencies to participation in the sub-committee’s functions;
  10. To work with other sub committees as appropriate to develop and disseminate learning through training, policies, procedures, guidance etc;
  11. Develop opportunities for joint working on common themes with the Safeguarding Adults Partnership Board.

Membership

Membership of the sub-committee is as follows:

  • Designated Nurse, CCG, (Chair);
  • Detective Inspector, FCIU, Merseyside Police;
  • Designated Doctor, Wirral University Teaching Hospital Foundation NHS Trust (WUTH);
  • Targeted Services Locality Manager;
  • Representative for Housing Providers;
  • Head of Safeguarding, NHS Community Trust Wirral;
  • District Manager, Children's Specialist Services;
  • Independent Reviewing Officer;
  • Named Midwife, WUTH;
  • Safeguarding Lead, Cheshire & Wirral Partnership NHS Foundation Trust;
  • WSCB Manager;
  • WSCB Quality Auditor (WSCB);
  • Headteacher.

The committee will be quorate with 3 agency representatives and the Chair present.


Appendix H: Terms of Reference for SCR Committee

Serious Case Review Committee

Terms of Reference

  1. To recommend to the WSCB Chair on the need to undertake a Serious Case Review (SCR) or Critical Incident Review (CIR) following a request from the WSCB or other organisation;
  2. To inform the national panel for SCR’s, Ofsted and the DfE of the intention to undertake a SCR;
  3. To discharge the responsibilities for managing a SCR or CIR as set out in the WSCB Learning and Improvement Framework including commissioning an independent overview report author (SCR) and identifying additional members to support the committee;
  4. To support the overview report author to undertake meetings, workshops and interviews as part of the SCR/CIR process;
  5. To develop resources and training to support colleagues involved in the SCR/CIR process;
  6. To ensure completion of the overview reports and presentation to the WSCB;
  7. To direct relevant agencies to identify actions and to construct the SCR/CIR action plan;
  8. To liaise with the Performance Committee to oversee completion of actions within timescales.

Membership

Permanent Membership of the sub-committee is as follows:

  • Head of Corporate Safeguarding (Chair);
  • Chief Inspector Merseyside Police;
  • Designated Doctor for Safeguarding (WUTH);
  • Designated Nurse for Safeguarding (CCG);
  • Education reps;
  • Assistant Chief Officer Merseyside Probation Trust;
  • Director, Merseyside Connexions Partnership;
  • Head of Housing Wirral Methodist Housing Association;
  • Consultant Headteacher;
  • Strategic Service Manager Integrated Youth Support.

The membership of the Committee will be widened as appropriate to include representatives from agencies directly involved in a case being reviewed.


Appendix I: Template for Significant Practice Event Chronologies

All agencies involved in the review will prepare SPE chronologies that identify risk, response, partnership and learning issues underpinning each episode.

  • Risk: Each Significant Practice Event must detail the presentation of risk;
  • Response: The response given by the agency is clearly presented;
  • Partnership: Understanding of multi-agency considerations is apparent;
  • Learning: The core of the SPE chronologies should identify learning opportunities, in particular those which are significant or new.

When preparing SPE chronologies agencies should consider the following:

  • Is this event one that changed/could have changed your assessment of the situation for the child?
  • Is this event symbolic or indicative of a pattern of events that individually would not otherwise be considered significant?
  • Is this a ‘statutory’ event e.g. child protection conference, court hearing or similar?
  • Would this have been an event that the child perceived as significant in their life?
  • Would this have been an event that a significant adult would perceive as significant in their life or the life of the child?
  • Has this event got significance as a learning point for agencies?

It is recommended that the Chronolotor software is used to support the completion of chronologies.

End