8.2 Serious Case Review Procedure
- Regulations and serious case review criteria
- Purpose of SCRs and other learning reviews
- Key Principles of SCRs and other forms of learning reviews
- Referring a case for review
- Considering a case for review
- Cross-border serious case reviews
- SCR Methodologies
- Cases that do not meet the criteria for SCR
- Process for conducting a serious case review
- Involving families
- Parallel Processes
- Freedom of information requests
- Publication of reports
- Media Interest
- Dissemination of learning
- Related Policies, Procedures, and Guidance
Working Together to Safeguarding Children states 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. Good practice should be shared so that there is a growing understanding of what works well. Equally, when things go wrong there needs to be robust and objective analysis of what happened and why, so that lessons can be learned and services improved to reduce the risk of future harm to children.
This procedure has been written to support the work of the Buckinghamshire Safeguarding Children Board (BSCB) and partners so that:
Regulations and serious case review criteria
Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of local safeguarding children boards (LSCBs). This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances where:
‘Seriously harmed’ in this context includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any of the following:
This definition is not exhaustive and, even if a child recovers, this does not mean that serious harm cannot have occurred.
Cases where (a) and either b(i) OR b(ii) have been met must always trigger an SCR.
Regulation b(i) includes cases where a child has died by suspected suicide.
Where a child has been seriously harmed, but has not died, unless there is definitive evidence that there are no concerns about inter-agency working, an SCR must be commissioned.
An SCR should always be carried out when a child dies (including suicide) in the one of the following circumstances, even if one of the criteria is not met:
Purpose of SCRs and other learning reviews
Reviews are not ends in themselve The purpose of reviews is to:
An SCR is not an inquiry into how a child has died – this is for the Coroner to investigate. It is not a criminal investigation to determine who is responsible – where necessary, that is for the police to determine. It is not a disciplinary investigation – where necessary, that is for individual agencies to deal with.
Key Principles of SCRs and other forms of learning reviews
SCRs and other forms of learning review should recognise the complex circumstances in which professionals work together to safeguard children. They should seek to understand who did what, and the underlying reasons that led individuals and organisations to act as they did, and they should try to do this from the viewpoint of those involved at the time, rather than using hindsight. The following key principles should be adhered to during any kind of review:
Referring a case for review
All partner agencies are responsible for identifying cases of concern that may meet the criteria for an SCR and bringing them to the attention of the BSCB.
Representatives of any partner organisation who feel that a case may meet the criteria for a SCR are encouraged to discuss this with the designated person/senior safeguarding representative within their own organisation before making a referral.
Professionals should consider the criteria set out in section 2. If they believe the criteria might be met, they should complete and submit an SCR referral form.
Where it is not clear whether a case meets the criteria for an SCR, or where an agency feels there would be benefit in conducting a learning review, the case should still be submitted to the SCR Sub Group for consideration using the SCR referral form.
Considering a case for review
The BSCB Business Manager will inform the Independent Chair of the BSCB and the Chair of the SCR Sub Group that a notification has been received and will ensure cases requiring consideration are placed on the agenda of the next SCR Sub Group meeting.
Working Together states that a case should be subject to a decision within one month of notification of the incident. Therefore, the BSCB Business Manager and Chair of the SCR Sub Group should agree whether an extraordinary meeting of the Sub Group is required to meet this timescale.
If the SCR Sub Group agrees that a case does or may meet the criteria for an SCR, the BSCB Business Manager will immediately notify all Board members that the case is being considered for an SCR and that information will need to be gathered to inform decision making and/or to feed into the first SCR Panel meeting. Board members will be asked to:
A clear timeframe will be provided for providing this information.
The discussions and decisions of the SCR Sub Group will be minuted. Decision-making should be evidence-based and explicit. Any disputes should be referred to the Independent Chair of the BSCB who has ultimate responsibility for the decision.
If the SCR Sub Group feels that information is missing, it may defer a recommendation and adjourn until further information is available and all the facts established. Such a delay may impact on the required timescales for making a decision. Therefore, agencies should ensure they provide full and comprehensive information at the earliest possible opportunity.
The Chair of the SCR Sub Group will put the Sub Group’s recommendation in writing to the Independent Chair of the BSCB within one month of the notification of the incident using section 2 of the SCR Referral Form (Appendix A). Dependent on the outcome of discussions, the recommendation will be one of the following:
The Independent Chair of the BSCB will make his/her decision upon receipt of this recommendation and reply in writing to the Chair of the SCR Sub Group using Section 3 of the SCR Referral Form (Appendix A).
The Chair of the SCR Sub Group will inform the referrer of the Chair’s decision.
The Chair of the BSCB will notify Board members of his/her decision. If the decision is not to initiate a SCR or any other type of learning review, Board members will be advised that associated records no longer need to be kept secure.
In cases where the BSCB Chair has decided to initiate a SCR, the Chair should provide the National Panel with the names(s) of the reviewer(s) appointed to conduct the SCR and the methodology that will be used for the review.
In cases where the BSCB Chair has decided not to initiate a SCR, the decision will be subject to scrutiny by the National Panel. The BSCB should provide information to the National Panel on request to inform its deliberations and the Chair of the BSCB should be prepared to attend in person to give evidence to the National Panel.
Cross-border serious case reviews
When the BSCB decides to conduct an SCR and agencies in other LSCB areas have been involved, the Chair of the BSCB will inform the Chair of any other relevant LSCB. Together they will agree whether the SCR will be conducted as: (a) a single LSCB review with limited input from the other LSCB; or (b) a joint SCR where members of each SCR Panel work together as an expanded panel.
This decision will depend on the complexity of the case and the degree of involvement of each partner agency.
When another LSCB instigates an SCR which involves agencies in Buckinghamshire, the Chair of the BSCB will respond to the request by notifying all relevant agencies and make requests for contributions on behalf of the other LSCB.
In such cases, the SCR Sub Group should have sight, at the earliest opportunity, of all findings and recommendations arising from local reports. This will ensure the BSCB is alerted to local issues to be addressed and can ensure that relevant local agencies are told about and implement any recommendations.
Working Together is not prescriptive about the methodology for an SCR. Any learning model can be used as long as it is consistent with the principles set out in this guidance and in Working Together.
There are a number of methodologies which can be used and the list below is not exhaustive. A relevant and proportionate methodology should be agreed by the SCR Sub Group on a case-by-case basis. Examples of methodologies include:
Cases that do not meet the criteria for SCR
The SCR Sub Group should consider an alternative form of learning review where the criteria for an SCR are not met. A relevant and proportionate methodology should be selected on a case by case basis. Examples include:
As with SCRs the BSCB will monitor the implementation of actions resulting from these reviews and reflect on progress in its annual report.
Process for conducting a serious case review
The process will vary depending on the methodology being used. A short process diagram is provided as a guide at Appendix A. This, along with the following guidance should be followed with some flexibility to fit the agreed methodology. Much of this is also relevant where a different form of learning review is being conducted and, in such cases, should be used as guidance.
The SCR Panel should aim for completion of an SCR within six months of initiating. If this is not possible (for example because of potential prejudice to related court proceedings), every effort should be made to ensure this does not prevent any learning being captured and any corrective action being taken.
Appointing an Independent SCR Author
Appointing an SCR Panel Chair
The SCR Sub Group should recommend a suitable person to act as Chair for the SCR Panel. This can be someone from a local agency as long as that agency was not involved in the case. The Chair should have relevant skills taking into account the specific issues in the case.
The SCR Panel Chair is responsible for:
The SCR Panel Chair and BSCB Business Manager should ensure that:
Setting up an SCR Panel
Role of the SCR Panel
The SCR Panel is collectively responsible for the quality, effectiveness and timeliness of the review. The specific functions of the panel are:
Developing the Terms of Reference
Individual Agency Reports
A chronology is a succinct summary and overview of the significant dates and events in the life of a child and their family. A chronology will usually be requested form participating agencies as part of an SCR.
Presentation of Final Overview Report and Combined Action Plans to the BSCB
It is good practice for relevant family members to be invited to contribute as fully as possible to the SCR process, unless there are clear reasons to exclude or limit their participation. This may include grandparents or siblings who were closely involved with the child and have a useful contribution about the family’s experiences of services. Although this is difficult and a painful time for the family, sensitive engagement should be sought. All attempts to engage should be fully recorded in the final report.
Responsibility for discussing and planning the family participation rests with the SCR panel and Chair. The panel should consider how and when it would be best for the family to contribute and who should facilitate their involvement and give feedback to the family. Each case is unique and it is therefore important that the SCR Panel carefully considers the best means of notifying families and how support may be offered to them, e.g. through existing services and/or the use of an advocate.
Families must always be informed that an SCR is taking place and an explanation given about what to expect, media coverage and that their names will be kept confidential. If the family does not wish to contribute or the Panel considers it to be inadvisable, the reasons should be fully recorded and included in the overview report.
Communication with family members should be face to face wherever possible, following communication to explain the purpose of the SCR and inviting them to contribute. It is good practice to allow any contributing family members to agree how their views are included and to see the report before it is published. Where possible the final report should clearly evidence how the family's views have been used to influence lessons learned from the review.
If there is a criminal investigation, the timing for interviewing family members will need to be arranged in conjunction with the legal processes. It is important that the SCR Panel receives appropriate advice and plans this carefully with the police Senior Investigating Officer, taking into account the views of the Crown Prosecution Service, with support from the Board legal adviser.
A number of other processes may take place alongside an SCR, including on-going criminal investigations, Coroner inquiries, Serious Adult Reviews, Domestic Homicide Reviews or single agency Serious Incident Reviews.
In most cases parallel processes should not delay the process of the SCR and every effort should be taken to avoid any delay in learning.
In all cases, an early meeting/discussion should take place between the SCR Panel Chair and relevant parties, such as the police, the Crown Prosecution Service or the Coroner, to clarify how the review can be progressed without delay and any instances where information may need to be shared. In some cases it may not be possible to fully complete or publish the review until after other processes are concluded, but this should not prevent lessons from being identified and implemented.
In the case of parallel criminal proceedings, advice must be sought from the police about whether interviewing involved staff or sharing information may prejudice these processes. Discussions should bear in mind CPS guidance on conducting SCRs alongside criminal processes.
Freedom of information requests
The Freedom of Information Act 2000 provides the public with a general right of access to information held by public bodies, such as local government, the police, the NHS and state schools. LSCBs are not public bodies and are therefore exempt from this Act.
However, unless there are exceptional circumstances, the BSCB will publish a full overview report and, where agreed, an executive summary of the SCR at the conclusion of the review or when any associated judicial enquiries are completed. Any additional information associated with SCRs should not be shared without the authorisation of the Independent Chair of the BSCB.
Publication of reports
Working Together states that all reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the BSCB’s website for a minimum of 12 months. Thereafter, the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs.
From the very start of the review process, the fact that the report will be published should be taken into consideration. The overview report should be written in such a way that publication will not be likely to harm the welfare of any children or adults involved in the case and it should be suitable for publication without needing to be amended or redacted.
The BSCB should publish, either as part of the SCR report or in a separate document, information about:
When compiling and preparing to publish reports, LSCBs should consider carefully how best to manage the impact of publication on children, family members and others affected by the case.
LSCBs must comply with the Data Protection Act 1998 in relation to SCRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders.
If an LSCB considers that a SCR report should not be published, it should inform Ofsted, the Department for Education and the National SCR Panel, which will provide advice to the LSCB. The LSCB should provide all relevant information to the National SCR Panel on request to inform its deliberations.
All media enquiries regarding SCRs must be referred to the Independent Chair of the BSCB via the BSCB Business Manager.
The BSCB will ensure that a media strategy is developed in advance of publishing an SCR, including, where appropriate, an agreed statement which will be shared with relevant partners. The BSCB will liaise with the local authority’s Communications Team and nominated media contacts of relevant partner agencies prior to publication to ensure all relevant parties are fully briefed.
Any media enquiries relating to services or individuals associated with an SCR should also be discussed with the BSCB Chair to ensure that consistent and clear messages are provided in a co-ordinated response.
Dissemination of learning
The BSCB Learning and Improvement Framework supports a culture of continuous learning and improvement across the organisations which work together to safeguard and promote the welfare of children.
Methods for sharing SCR learning include:
Referral to Serious Case Review Sub Group
Working Together provides clear criteria (in Chapter 4) about when the Buckinghamshire Safeguarding Children Board (BSCB) should conduct a Serious Case Review (SCR).
For cases that do not meet the criteria for an SCR, the Sub Group will consider where another form of partnership or learning review may be appropriate to ensure lessons are learned.
Where partners feel a serious incident does not meet the definition for a SCR, but cannot be dealt with internally by the referring agency alone, the Sub Group can consider making a recommendation on whether there should be a wider review involving more than one agency. This form should also be used for referring such cases.
Anyone wishing to refer a case to the SCR Sub Group should discuss the case, and their reasons for referring it, with their agency’s Designated Safeguarding Lead/Officer before making the referral. They should then notify the BSCB as soon as possible.
Please send the completed form to: firstname.lastname@example.org
Appendix A Download the form here
Related Policies, Procedures, and Guidance
- Completing Chronologies: Guidance
- Learning and Improvement Framework
- Neglect Guidance
- Child Death Overview Panel Procedure
- Rapid Response Procedure