12.1 Learning and Improvement (Including Serious Case Reviews)


This chapter covers the requirements within chapter 4 of Working Together to Safeguard Children 2018, 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.

1. Principles

Principles for a Culture of Continuous Improvement

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.

2. Serious Case Review Process

2.1 Criteria

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:

  1. Abuse or Neglect of a child is known or suspected; AND
  2. Either:
    1. The child has died; OR
    2. The child has been seriously harmed; and
    3. 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:

  1. Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
  2. 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.

2.2  Methodology for Learning and Improvement

The NSCB does not work to any prescribed or 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.

2.3 Appointing Reviewers

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.

2.4 Timescale for Serious Case Review Completion

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.

2.5 Engagement of Organisations

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.

2.6 Agreeing Improvement Action

The LSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings.

2.7 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 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.

2.8 Local Processes

  • 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.
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