Article: Serious Case Reviews
Serious Case Reviews play a vital role in helping local
professionals and organisations to continually improve the way they
work, individually or together, to keep children safe and free from
harm.
When a child dies, and abuse or neglect are known or suspected
to be a factor in the death, Barnsley Safeguarding Children
Board will always undertake a Serious Case Review; firstly to
consider whether there may be other children at risk of harm, such
as siblings, and secondly to get a better understanding of how
agencies involved with the child worked together, how and why
decisions were made, and what lessons can be learned.
What is a serious case review?
This is the formal process that brings together information
from all the agencies involved with the child and
its family leading up to the child's death. From
these records, a complete picture of the case can
be drawn up in the form of a final overview report, which
includes analysis of all contact with the child and
its family, any decisions that were made, the
conclusions that were drawn and any recommendations for
action.
When do serious case reviews take place
Serious Case Reviews are always undertaken
when a child dies (including suicide), and abuse or neglect
is known or suspected to be a factor in the death
They can also be undertaken where:
- a child sustains a potentially life-threatening injury or
serious and permanent impairment of physical and/or mental
health and development through abuse or neglect
- a child has been seriously harmed as a result of being
subjected to sexual abuse
- a parent has been murdered and a domestic homicide review is
being initiated under the Domestic
Violence Act 2004
- a child has been seriously harmed following a violent assault
perpetrated by another child or adult
- the case gives rise to concerns about inter-agency working to
protect children from harm.
Why do serious case reviews take place?
Serious Case Reviews are not inquiries into how a child died or
was seriously harmed, or into who is to blame. These are matters
for coroners and criminal courts to determine as appropriate. The
focus of Serious Case Reviews is to identify improvements
to practice to safeguard and promote the welfare of
children by:
- establishing what lessons need to be learned from the case
about the way in which local professionals and organisations work
individually and together to safeguard and promote the welfare of
children;
- identifying clearly what those lessons are both within and
between agencies, how and within what timescales they will be acted
on, and what is expected to change as a result
- improving intra- and inter-agency working and better safeguard
and promote the welfare of children.
Local Safeguarding Children Boards have a duty to publish an
anonymised version of the Overview Report and Executive
Summary of any Serious Case Reviews that they have
conducted. This will include an overview of the case,
the terms of reference, conclusions drawn and any
recommendations made.
Serious Case Reviews are a major element of
the Safeguarding Board's Learning and
Improvement Framework which sets out how the Board will learn
lessons from tragic events and put in place measures to reduce the
likelihood of such events reoccurring.
National Findings from Serious Case Reviews
Ofsted no longer evaluate Serious Case Reviews as set out
in
Working Together to Safeguard Children 2013, in
line with recommendations from the Munro Review. However
they have previously published a report,
Learning Lessons from Serious Case Reviews 2009 -
2010, that provides an analysis of 147 serious
case reviews completed between 1 April 2009 and 31 March
2010.
In addition, a report published in October 2011 entitled
"Ages of concern: learning lessons from serious case
reviews" provides a thematic analysis of 482 serious
case reviews evaluated between 1 April 2007 and 31 March 2011. The
main focus of this report is on the reviews that concerned children
in two age groups: babies less than one year old and young people
aged 14 or above.
National Panel of Independent Experts on Serious Case
Reviews
In June 2013 a National Panel of Independent Experts was
established to support Safeguarding Boards in ensuring that
appropriate action is taken to learn from serious incidents in
cases where the criteria are met and to ensure that lessons learned
are shared through publication of the final report. In July
2014 the Panel published its
first annual report, in which it comments on decision
making by Safeguarding Boards and the quality of published Serious
Case Reviews.
The NSPCC produces a useful series of
briefing papers containing findings from Serious
Case Reviews against various themes
Published Serious Case
Reviews
The links below provide access to the
most recent Serious Case Review commissioned by Barnsley
Safeguarding Children Board
Completed Serious Case Reviews
are also published by other Safeguarding Children
Boards. The NSPCC, in collaboration with the Association
of Independent LSCB Chairs has developed a
national repository of published Serious Case
Reviews so that the learning contained within
them is easier to access. It has also published a
thematic briefing that pulls together and
highlights the learning from case reviews into the death or serious
injury of a child where parental substance misuse was a key factor,
based on case reviews published since 2010.
Below are links to some recent high
profile Reviews that may contain relevant lessons for
Barnsley.
Barnsley Safeguarding Children Board Policies and
Procedures are available
here