Serious Case Reviews
What are Serious Case Reviews?
A Serious Case Review is a review of services that have been provided to a child and family prior to the death or serious injury of a child where abuse or neglect are believed to be a contributory factor. LSCBs are required to undertake Serious Case Reviews under regulation 5 of the Children Act 2004 and guidance for this is contained in Chapter 8 of Working Together to Safeguard Children (2006): The purpose of the review is to:
• establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children
• identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and
• as a consequence, to improve inter-agency working and better safeguard and promote the welfare of children.
The Hampshire Safeguarding Children Board (HSCB), along with other local LSCBs, has developed a detailed Serious Case Review Protocol. This Protocol will continue to develop as further statutory guidance is published. 4LSCB Serious Case Review Protocol
When are Serious Case Reviews undertaken?
Hampshire Safeguarding Children Board undertakes Serious Care Reviews in cases where:
· a child had died and abuse or neglect of a child is known or suspected
· a child has been seriously harmed, where abuse or neglect of a child is known or suspected and there is cause for concern as to the way in which agencies have worked together to safeguard the child.
Who carries out Serious Case Reviews?
Serious Case Reviews are commissioned by the HSCB. An Independent Author and Independent Chair are appointed. In each case, a Panel of senior professionals, drawn from relevant Hampshire agencies is established to contribute to the analysis of the services provided and identify what lessons can be learnt. Each agency which has been involved in the case is required to produce an Individual Management Review (IMR) on their contact and actions during the timescale of the review and if necessary, to make recommendations about how services may be improved. Whenever possible, the child and family are asked to contribute to the review. The Overview report, is written by an author who is independent of any Hampshire agencies,
Recommendations for practice, procedural or training changes are made by the Overview Author and presented to the HSCB, which takes responsibility for developing an Action Plan.
The HSCB then monitors the action plans of both the Individual Agency Management Reviews and additional recommendations that the Panel may have made as part of the SCR process.
The Review is conducted within national timescales and submitted to Ofsted who monitor the work of LSCBs.
Information for families is contained within our SCR leaflet.
Learning Lessons from Serious Case Reviews
Serious Case Reviews often find a combination of good service provision and good practice, alongside lessons to be learned about how these can be improved to help ensure that such events do not happen again. Members of the HSCB take these lessons back to their agencies to disseminate the learning. This learning is also disseminated through single and interagency training and development, and the implementation of the action plans.
Hampshire County Council Training
To help disseminate learning and to provide public accountability, an anonymised Executive Summary of the findings is published on completion of the SCR and made available to the public.
Executive Summaries of local Serious Case Reviews
A copy of Executive Summaries of Serious Case Reviews undertaken by Hampshire Safeguarding Children Board can be obtained by calling the HSCB Manager on 01962 876230 or emailing hscb@hants.gov.uk.
Prior to public publication, each Executive Summary requires careful anonymisation to protect the identification of any children, family of other individuals involved. HSCB also shares the report findings with the family whenever possible.
The HSCB is in the process of publishing reviews undertaken from April 2007. The following reviews are currently available:
Learning from National Reviews
Every two years, an overview analysis of serious case reviews in England is commissioned, by the Department of Children Schools and Family (DCSF). The lessons learned from a number of cases are shared and developing themes and trends are highlighted to inform both policy and practice. The latest report “Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2005-2007” states that:
“A detailed study of 40 serious case reviews revealed that almost half (45%) of the families
were highly mobile and were living in poor conditions. Half of the parents/ carers had criminal
convictions. Many families were overwhelmed, with poor or negative family support. Nearly
three quarters of the children lived with past or present domestic violence and / or past or
present parental mental ill health, and / or past or present parental substance misuse. These
three parental characteristics often co-existed.” page 3
“Three quarters of the 40 families did not co-operate with services. Patterns of hostility and
lack of compliance included: deliberate deception, disguised compliance and “telling workers
what they want to hear”, selective engagement, and sporadic, passive or desultory
compliance. Reluctant parental co-operation and multiple moves meant that many children
went off the radar of professionals. However, good parental engagement can sometimes
mask risks of harm to the child.” page 3
“The chaotic behaviour in families was often mirrored in professionals’ thinking and actions.
Many families and professionals were overwhelmed by having too many problems to face
and too much to achieve. These circumstances contributed to the child being lost or unseen.
The capacity to understand the ways in which children are at risk of harm is complex and
requires clear thinking. Practitioners who are overwhelmed, not just by the volume of work
but also by its nature, may not be able to do even the simple things well. Good support,
supervision and a fully staffed workforce is crucial” page 1
Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2005-2007 DCSF
Further information on Serious Case Review can be obtained from the DCSF Every Child Matters website: Every Child Matters - Serious Case Reviews
