Serious Case Reviews – resources for practitioners

Serious Case Reviews (SCR) play a vital role in helping practitioners and organisations to continually improve the way they work, individually or together, to keep children and young people safe and free from harm.

A Serious Case Review (SCR) is the formal process that brings together information from all the agencies involved with a child and their family leading up to the incident. From these records, a complete picture of the case can be drawn up in a report, which includes analysis of all contact with the child and family, any decisions that were made, the conclusions made and any recommendations for action.

When and why do Serious Case Reviews take place?

When do SCRs take place?
SCRs are carried out for every case where abuse or neglect is known or suspected and either:

  • a child has died or;
  • a child has been seriously harmed and there are concerns about how organisations or professionals worked together to protect the child.

The full criteria are specified in Working Together to Safeguard Children.

A SCR 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 secure children’s home.

The same applies where a child dies who was detained 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.

SCRs 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;
  • 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 SCRs take place?
The purpose of SCRs is to identify improvements which are needed and to consolidate good practice. SCRs are not enquiries into how a child died or was seriously harmed, or into who is to blame. These are matters for the coroners and criminal courts as appropriate.

SCRs 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 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 to better safeguard and promote the welfare of children.

The findings from SCRs are translated into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.

Local Safeguarding Children Boards have a duty to publish an anonymised version of the SCR Report. This will include an overview of the case, the terms of reference, conclusions drawn and any recommendations made.

SCR reports are published for a minimum of twelve months; reports published prior to this should be available from the NSPCC SCR repository.

Serious Case Reviews are a major element of our learning and improvement framework which sets out how we will learn lessons from tragic events and put in place measures to reduce the likelihood of such events reoccurring. Working Together 2015 requires a LSCB to publish information about actions which have been taken in response to the findings of serious case reviews.

MSCB SCR Referral Process 

If an individual or agency feels a case should be referred for a SCR they should complete the MSCB SCR Referral Form (Dec 2017) and partner agencies are asked to contribute any information they may have about the case. This is then screened by the SCR Subgroup to determine if it meets the criteria.

If you become aware of an incident or case:

  • discuss it with a senior manager and/or your agency SCR Subgroup member;
  • if required, your agency SCR Subgroup member or a senior manager should hold an initial discussion with the MSB Review Coordinator;
  • the SCR Subgroup member or senior manager should complete the SCR Referral form and submit it to the MSB Review Coordinator by email to manchestersafeguardingboards@manchester.gov.uk

The MSCB SCR Referral Form (Dec 2017) replaces any previously used forms.

If you have any queries please contact the MSB Review Coordinator or the MSB Business Unit.

COMPLETED FORMS SHOULD BE SENT TO THE MSB INBOXmanchestersafeguardingboards@manchester.gov.uk

Carrying out MSCB Serious Case Reviews

MSCB SCRs are led by an independent reviewer who has no connection to the case, or to the organisations whose actions are being reviewed.

Practitioners involved with the child or family in the case are fully involved in SCRs. They are invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

Families are also invited to contribute to SCRs. We work hard to make clear to them how they are going to be involved and mange their expectations appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.

SCRs should be conducted in a way which:

  • 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;
  • is transparent about the way data is collected and analysed; and
  • makes use of relevant research and case evidence to inform the findings.

The MSCB follows the principles of the North West Learning and Improvement Framework, within the Greater Manchester Safeguarding Partnership (GMSP) procedures which can be found at  greatermanchesterscb.proceduresonline.com

MSCB published Serious Case Reviews

The MSCB publishes its Serious Case Reviews (SCR) online for twelve months.

All current and historical MSCB publications can be found via the NSPCC National Case Reviews Repository

Current published reports:

All media enquiries relating to the publication of SCRs should be made to the MSB Communications Manager on tele: 0161 234 3330 / 1828 or email: manchestersafeguardingboards@manchester.gov.uk

MSCB SCR Learning Packs – resources for practitioners

Learning packs for completed SCRs are made available on the website as soon as practicable and often prior to publication. These can be used by individual agencies for internal cascading within their organisation to make sure that the valuable lessons learned are shared across staff teams.

Supporting learning events, which are planned to take place on a monthly basis, will be advertised on the MSB Training website.

Child G1 SCR: Learning event held September 2017; full report to be published in due course

Child H1 SCR: Learning event held October 2017; full report published 14.12.2017

Child I1 SCR: Learning event held November 2017; full report published 14.12.2017

Child J1 SCR: Learning event held  December 2017; report not published

Child K1 SCR: Learning event to be held early 2018; full report published 14.12.2017

National Learning from SCRs

NSPCC thematic briefings
The NSPCC produces a useful series of briefing papers containing findings from Serious Case Reviews against various themes – these can be found on thier website www.nspcc.org.uk

National Panel of Independent Experts on Serious Case Reviews
The National Panel of Independent Experts was established to support LSCBs to make sure that appropriate action is taken to learn from serious cases and to ensure that lessons learned are shared through publication of the final report.

The Panel published its second annual report 10 November 2015 in which it comments on decision making by Safeguarding Boards and the quality of published Serious Case Reviews – find these reports on the website www.gov.uk

National Findings from Serious Case Reviews
Ofsted no longer evaluate Serious Case Reviews as set out in Working Together to Safeguard Children 2015,  in line with recommendations from the Munro Review – read more on the website www.workingtogetheronline.co.uk

Ofsted have previously published reports summarising lessons learnt from SCRs:

  • Learning Lessons from Serious Case Reviews 2009 – 2010 analysis of 147 serious case reviews completed between 1 April 2009 and 31 March 2010.
  • Ages of concern: learning lessons from serious case reviews published October 2011 provides a thematic analysis of 482 serious case reviews evaluated between 1 April 2007 and 31 March 2011.

NSPCC National Case Reviews Repository

The NSPCC National Case Reviews Repository was launched in 2013 in collaboration with the Association of Independent LSCB Chairs.

The repository provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.

The repository is accessible via the NSPCC library online, which has over 800 case reviews and inquiry reports dating back to 1945.

The NSPCC website has further information about the Repository, research on case reviews and a list of all learning from case review briefings.

Practitioners can:

  • Sign up direct for alerts from the NSPCC website
  • Obtain a list of reports held in the Repository for a LSCB or topic:
    • Open the NSPCC library catalogue
    • Under Advanced search
    • Select Publisher from the Search in drop-down menu
    • Enter the relevant name in the Search terms box e.g. Manchester
    • Select Case reviews from the Media type drop-down menu.

Legislation and guidance 

SCRs are conducted under the guidance of Working Together To Safeguard Children 2015 (Chapter 4).

Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the function of LSCBs.

The Association of Independent LSCB Chairs website publishes a number of useful document and links; these include advice relating to the publication of anonymised SCRs.

MSCB SCR resources for reviewers and practitioners involved in the SCR process

The MSCB SCR Guidance Procedures (Published October 2017)  have been developed to support reviewers, practitioners and support staff involved in the SCR process.

The Information sheet on Practitioner Learning Events (June 2017)  can be given to practitioners asked to attend a learning event.

MSCB SCR resources for families

It is essential that families are made aware that a Serious Case Review is taking place and that they are offered the opportunity to contribute to the review process. Early discussions will be needed with the child or young person, family and friends (identified as appropriate by the Review Panel) and they should be informed of concerns and that a SCR is underway.

Information for families about the SCR process can be found on the MSCB SCR Family Information sheet (Aug 2017)

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