8.2 Serious Case Review Procedure

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:

• Serious Case Reviews (SCRs) are conducted in line with statutory requirements
• alternative forms of review are undertaken where the criteria for an SCR are not met but there is a need to explore the way agencies are working together to safeguard and protect the welfare of children
• actions arising from reviews result in improvements to services and outcomes for children.

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:

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 children          

‘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:

• A potentially life-threatening injury
• Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

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:

• in custody
• in police custody
• on remand
• following sentencing
• in a young offender institution
• in a secure training centre
• in a secure children’s home
• where detailed under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

Reviews are not ends in themselve The purpose of reviews is to:

• establish whether there are lessons to be learned, including good practice, about the way local professionals and organisations safeguard and promote the welfare of children
• identify what those lessons are, how and when they will be acted on, and what is expected to change as a result
• disseminate and embed good practice and any required improvements
• promote a continuous learning and improvement culture which improves outcomes for children and young people.

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.

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:

• Timely: Agencies must respond to a decision to undertake an SCR/learning review with appropriate urgency and should aim to conclude an SCR within statutory timescales (six months from the date of decision to proceed). Ofsted, the Department for Education and the National Panel will be kept informed of any delays relating to the decision making process around an SCR, or any delays during the SCR process.
• Impartial: The BSCB is independent of any of its partner agencies and the review must be conducted fairly and impartially. Anyone who has direct involvement with the child or their family should not be responsible for drafting reports, sit on or Chair the SCR panel, or facilitate another form of learning review.
• Thorough: It is essential that a case is considered fully and that all staff with relevant information, and where possible the family, have the opportunity to contribute. Relevant research and case evidence should be used to inform findings.
• Proportionate: The approach taken to reviews should be proportionate to the scale and level of complexity of the issues being examined.
• Child focused: The journey, experiences and outcomes for the child should remain central to the review. Where possible, families, including surviving children, should be invited to contribute to reviews.
• Open: The BSCB should be open with the family and others affected by the review regarding the process and outcomes. The review should be conducted in a way that encourages those involved to be open and transparent about what happened and the reasons for this. Professionals should be able to contribute their perspectives without the fear of being blamed for actions they took in good faith.
• Confidentiality: All information gathered throughout the review process must be treated as highly confidential and only shared or disclosed where appropriate and where agreed by the SCR Panel/SCR Sub Group. Appropriate secure methods should be used for sharing information and those involved in the review should ensure that any printed material is treated as confidential and disposed of accordingly once no longer needed.
• Cooperation: The full cooperation of all agencies involved in the review will be required to ensure a successful outcome for the review. This includes ensuring that staff involved in the review have sufficient capacity to carry out their role and meet deadlines. The BSCB Escalation Procedures should be followed where full cooperation is not provided.

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.

LSCBs are also required to consider conducting reviews on cases which do not meet the SCR criteria. In such cases, the BSCB may decide to commission some other form of learning review.

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.

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:

• confirm whether the child and family are known to their agency
• provide a brief outline of this involvement
• secure all related records (paper and electronic) in accordance with the agency’s agreed processes to guard against loss or interference. Where a case is still active, or work is being undertaken with other family members, arrangements should be made for practitioners to have access to records, as necessary.

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:

• scr to be commissioned
• criteria for an SCR not met- alternative form of learning review recommended
• criteria for an SCR not met – no alternative form of learning review recommended

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.

Although the final decision rests with the Chair of the BSCB, the Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process

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.

The Chair of the BSCB will advise Ofsted, the Department for Education and the National Panel of Serious Case Review Experts of his/her decision within five working days, as per Working Together 2018.

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.

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:

• The Social Care Institute for Excellence (SCIE) Learning Together: This method values practitioner contributions and is sympathetic to the context of the case.
• Root Cause Analysis (RCA) has often 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 SCR system as the statutory guidance in Wales in 2013. This process places an emphasis on involving agencies, staff and families in a collective endeavour to reflect and learn from what has happened. It takes a streamlined, flexible and proportionate approach to reviewing.
• Significant Incident Learning Process (SILP): This is a learning event where agencies come together with a facilitator to review the case together, identify learning and agree any actions. After the event, the facilitator should produce a report summarising learning.
• Appreciative Inquiry (AI), rooted in action research and organisational development, AI is a strengths-based, collaborative approach for creating learning change. SCRs 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 wisdom to design practice improvements.

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:

• Partnership review: The methodologies outlined for an SCR in section 9 could be used or adapted. The SCR Sub Group will identify a lead reviewer and determine the terms of reference, timescales and methodology to be adopted. The format and content of information required from agencies will depend on the terms of reference for the review and the agreed methodology. The lead reviewer should produce a report summarising learning. This should be agreed by the SCR Sub Group before being submitted to the BSCB.
• Single agency review: This is a review of case that is carried out by an individual agency. When the BSCB Chair agrees to a recommendation for a single agency review, he/she will write to the Board Member or Lead for Safeguarding in the relevant agency recommending that a single agency should be undertaken. The findings of the single agency review should be shared with the SCR Sub Group before being submitted to the BSCB.
• Auditing of practice (single or multi-agency): In some cases the SCR Sub Group may feel that an audit of practice would be appropriate. Where a multi-agency audit is recommended, the Chair of the BSCB should ask the Chair of the Performance and Quality Assurance Sub Group (P&QA) to lead this work. Where a single agency audit is recommended, the BSCB Chair will write to the agency concerned and ask them to report their findings to the P&QA Sub Group.

As with SCRs the BSCB will monitor the implementation of actions resulting from these reviews and reflect on progress in its annual report.

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

• The BSCB will appoint one or more suitable individuals to write an overview report. Where an SCR is being conducted, the author must be independent of the BSCB, of partner organisations involved in the case and from professionals and SCR Panel members involved in the case. The author must have demonstrated that they are qualified to conduct reviews using the principles set out in Working Together 2015 and in line with the agreed review methodology.
• The author will be commissioned by the BSCB Business Manager in accordance with the BSCB’s standard contract for Independent Authors.
• The author is responsible for:
  • Reading and analysing agency chronologies, reports and information to identify key issues and learning.
  • Writing an overview report to set out the learning, including appropriate and proportionate recommendations for action, and, where agreed, an executive summary.
  • Dependent on the methodology being used, the author may also have a role in designing and facilitating learning events and seeking the views of family members.
• The author is not a member of the SCR Panel, but would usually be invited to attend SCR Panel meetings and other meetings or events relevant to the review to be part of the discussion and analysis.
• In producing the overview report, the author should:
  • consider all information submitted to the Panel
  • ensure that, wherever possible, the views/experience of the child and their family are incorporated into the findings
  • ensure that the views/experience of staff and managers who were involved in the case are taken into account
  • ensure that the reports anonymise the child, family members and staff using the codes agreed by the Panel
  • ensure the overview report is based on fact and is open, honest and transparent
  • ensure that recommendations are clear, robust and SMART (Specific, Measurable, Attainable, Relevant, Time-bound)
  • ensure the report fulfils the terms of reference for the review.
• In producing the final draft, the Overview Author should satisfy the SCR Panel that all issues raised by the Panel have been addressed.

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:

• ensuring the SCR Panel operates effectively so that organisations and agencies collaborate to produce a comprehensive and timely SCR which identifies the lessons to be learned and establishes a framework to ensure they are learned
• ensuring all those involved in the review are clear of the purpose of the SCR, the process to be applied, and of their individual roles, responsibilities and tasks
• ensuring agency reports are quality assured
• liaising with the LSCB Business Manager and Chair to agree a revised timescale if the statutory timescale is unlikely to be met
• ensuring the draft report is considered against the agreed Terms of Reference to ensure that they have been fulfilled
• ensuring that the final report is comprehensive, well written and meets the requirements of Working Together
• ensuring the views of all panel members are heard and given equal weight during the review so that robust dialogue can take place.

The SCR Panel Chair and BSCB Business Manager should ensure that:

• expert advice is available to the SCR Panel if required
• objectivity and challenge are applied throughout the process
• the final report is entirely and consistently anonymised with no loss of meaning and that all information remains confidential
• progress is managed robustly to meet statutory deadlines and agreed timescales
• legal advice is available to the panel via the BSCB legal adviser
• the BSCB Independent Chair is kept up to date on the progress of the review
• action is taken to investigate and attempt to resolve any disputes or issues of non-compliance by participating agencies – where necessary any ongoing disagreements or challenges which arise during the SCR process should be referred to the LSCB Chair
• the Overview Author has all the necessary information and act as a point of contact for the author should any questions arise.

Setting up an SCR Panel

• The SCR Sub Group will identify initial panel member Members. Panels should include senior representatives of the agencies involved in the case or specialists in the professions involved. These representatives should be independent of the case under review, having had no direct management involvement and must have sufficient seniority to be able to comment on their agency’s practice. The panel may also include representatives from other non-involved partner agencies to ensure further independence and support for the SCR process. Legal advice should be available to the Panel via the BSCB legal adviser, who may sit as a member of the Panel or, where appropriate, provide advice to the Panel where required. The panel may also co-opt additional members in relation to specific issues that arise during the SCR process.
• Panel members should not also be responsible for writing agency reports as this could lead to a conflict of interest and prejudice their independence.
• The expectation is that membership of the Panel will remain constant. Agencies should ensure that sufficient time is allocated to enable the representative to effectively undertake the work of the SCR Panel.
• The membership of the Panel may need to be extended, once the terms of reference have been established.

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:

• Determine the scope of the review, draw up clear terms of reference and keep these under review throughout the SCR process.
• Select the time period over which events are reviewed, and consider whether these may need to be reviewed in the light of any new information provided. Where families have been known to agencies for many years a summary of involvement prior to recent years may be sufficient to allow the review to concentrate on the detail of recent events.
• Set a clear timescale for the completion of the review and plan review activity so that this timescale will be met.
• Aim to complete the review within six months, including planning for any anticipated delays, ensuring that any delays are kept to a minimum and where there are delays this does not hinder the learning process.
• Identify the agencies and professionals that need to provide information.
• Ensure that appropriate knowledge and expertise for the case is represented in the membership of the panel.
• Ensure that all staff are supported to participate in the review, including taking specific responsibility for making sure staff in their own agency understand the tasks that are required of them.
• Scrutinise and challenge reports provided by agencies to ensure they adhere to the terms of reference, are based on sound evidence and reasoned findings and to identify gaps in knowledge or resolve conflicting information.
• Request additional information and ensure reports are clear and of a high quality.
• Ensure the child’s experience is kept at the centre of the process.
• Consider how best to notify and involve relevant family members..
• Agree and implement arrangements for anonymity.
• Consider the impact of parallel processes, e.g. criminal investigations or disciplinary procedures.
• Agree arrangements for working with other LSCBs where necessary.
• Take account of any legal advice provided to the Panel.
• Ensure that report authors selected by their respective agencies are sufficiently independent from the case.
• Ensure that any learning is translated into action plans and that reports and action plans take account of any learning that has already been implemented (see for action plan template).
• Ensure the overview report considers all aspects of the terms of reference.
• Ensure the overview report fully consider the information contained in agency reports.
• Ensure the evidence, analysis and findings presented by the Overview Author receive robust scrutiny, and are challenged where necessary to ensure a credible and influential conclusion for the review.
• Ensure that the overview report is written in a style that is understandable for both professionals and the general public.

Developing the Terms of Reference

• The preliminary SCR Panel must agree terms of reference to ensure the review incorporates all relevant issues. These should be sent to the Chair of the BSCB for approval.
• Time spent on this part of the process is crucial and will affect the quality of reports and, ultimately, lessons arising from the overview report.
• Better outcomes can be achieved if everyone involved in the SCR addresses the same questions and issues pertinent to the case. Consequently, the terms of reference will be incorporated into all report templates.
• The initial scope and terms of reference for the review may need to be revised if significant new information emerges during the review, e.g. they might identify other key agencies/organisations involved or they might indicate that the timeframe for the review needs to be adjusted to allow focus on a particular period

Individual Agency Reports

• A template agency report is provided with the action plan template. However, the SCR Panel will need to decide what type of reports are required dependent on the SCR methodology being used and adapt the template as necessary. The SCR panel should give appropriate guidance to ensure that those providing information are clear about what is required.
• Report authors should be independent of any direct involvement or line management of the case under review. They should also have access to supervision from a line manager who has had no direct involvement in the case. The independence of the author from the case should be clearly recorded in their report.
• The author must be sufficiently senior and be able to challenge existing practice and be credible within the organisation. They should have sufficient knowledge and expertise to objectively analyse their agency’s involvement effectively and make required recommendations for change.
• The author must work with the relevant SCR Panel member to ensure that all relevant agency staff are informed of the purpose of the report and the background to and process for the SCR.
• The organisation should ensure the author is given access to staff, paper and electronic records and files. The author may want to speak to or interview staff central to the case. In addition, staff who wish to be interviewed should be offered this opportunity. The organisation must ensure adequate time and resources are provided to the author to complete the work within the agreed BSCB timescale
• Each agency report should be quality assured, agreed and signed off by an appropriate senior manager before being submitted to the SCR Panel. The final version must be signed and dated by the report author and by an appropriate senior manager.
• Any recommendations made within agency reports should be SMART (Specific, Measurable, Achievable, Realistic, Timely).
• Some agencies may have designated teams or officers responsible for undertaking SCR reports. If an appropriately skilled and independent author cannot be identified internally, the organisation should consider contracting an author from outside of the organisation.

Agency Chronologies

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

• Once the SCR Panel has agreed the final overview report and action plan, these should be submitted to the SCR Sub Group and to the Independent Chair of the BSCB for consideration. Once the Sub Group has reviewed the overview report and action plan, they should be submitted to the BSCB for final scrutiny and approval. Usually an extraordinary BSCB meeting will be scheduled for Board members to sign off an SCR. This is to ensure there is sufficient time for a robust discussion and consideration of learning and any further actions to be taken.
• The Overview Author is usually required to present their report to the BSCB and will need to make any amendments that are mutually agreed through discussion at the Board.
• Relevant Board members should identify a senior officer within their organisation to oversee their agency’s action plan and ensure that progress on the actions is reported back to the BSCB’s SCR Sub Group within agreed timescales. The SCR Sub Group will report regularly on progress to the BSCB and escalate to the relevant agency’s BSCB member and then to the Independent Chair of the BSCB where there is insufficient evidence of progress or updates are not provided on a regular basis.

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.

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.

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:

• actions which have already been taken in response to the review findings
• the impact these actions have had on improving services
• what more will be done.

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.

LSCBs should send copies of all SCR reports to Ofsted, the Department for Education and the National SCR Panel at least one week before publication.

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.

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:

• During the SCR process
  • Discussion and reflection in interviews undertaken by report authors with staff involved in the case.
  • Discussion and debate at SCR panel meetings
  • Fast-tracking of significant issues to the BSCB and/or individual agencies throughout the review process, e. not delayed until outcome of review
  • Learning events held with the practitioners involved in the case
  • Feedback and consultation with relevant family members.
• After the SCR process
  • Presentation and discussion of learning points at the Safeguarding Board
  • Dissemination of learning points through dedicated briefing or learning sessions, team meetings, training events or newsletters.
  • The incorporation of lessons learned across BSCB training, policies, procedures and guidance documents, performance and quality assurance activity.
  • Publication of overview report on the BSCB website
  • Sharing learning points across LSCB networks through regional forums
• The SCR Sub Group is responsible for agreeing and overseeing BSCB activity to disseminate learning, although it may be appropriate for this to be done through joint working across Sub Groups.
• Individual agencies also need to take responsibility for ensuring that appropriate action is taken to disseminate learning from SCRs within their own agency. The BSCB section 11 audit will allow the BSCB to gain assurance around how individual agencies disseminate learning from SCRs and other forms of review within their own agency. Where necessary, the SCR Sub Group may also ask agencies to provide additional information.

Appendix A

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).
 
BSCB partner agencies should ensure that serious incidents which may meet the criteria for an SCR are also brought to the attention of the BSCB SCR Sub Group using this form.

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: secure-bscb@buckscc.gcsx.gov.uk

Appendix A Download the form here

Appendix B To download the SCR Process diagram please click here

Appendix C To download the Agency Report template please click here

Appendix D To download the BSCB Serious Case Review Action plan please click here