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Guidance to Local Safeguarding Children Boards (LSCBs) on action to be taken on Serious Case Reviews (SCRs)
On 15 December 2008, the Rt Hon Beverley Hughes MP, Minister for Children, Young People and Families, wrote a letter to all chairs of LSCBs and enclosed a guidance note on action to be taken by LSCBs on SCRs.
Chapter 8 of Working together to safeguard children sets out the purpose and process of Serious Case Reviews (SCRs). SCRs are undertaken when a child dies (including suicide), and abuse or neglect is known or suspected to be a factor in the death. Additionally they can be undertaken where:
- a child sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect
- a child has been subjected to particularly serious sexual abuse
- a parent has been murdered and a homicide review is being initiated
- a child has been killed by a parent with a mental illness
- or the case gives rise to concerns about inter-agency working to protect children form harm.
The purposes of SCRs are to:
- establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard and promote the welfare of children
- identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result
- and, consequentially, improve inter-agency working and better safeguard and promote the welfare of children.
Process for a Serious Case Review (SCR)
The LSCB needs to decide whether or not a case should be the subject of an SCR, applying the criteria in Working together to safeguard children (paragraphs 8.5–8.9). In doing so, LSCBs should establish a Serious Case Review Panel, involving at least LA children's social care, health, education and the police.
Immediately following the Review Panel's decision of whether or not to conduct an SCR, the local authority should inform Ofsted of the LSCB's decision. This information will be passed to the DCSF and relevant Government Office (GO) by Ofsted.
Working together (paragraphs 8.14–8.16) sets out the timings for the SCR process and these timing should be adhered to at all times. In particular, two timescales are most important.
- The decision to conduct a SCR (or not) must be made within one month of the LSCB Chair being made aware of the incident (see Working together paragraph 8.14).
- The SCRs should be completed within four months, unless an alternative timescale is agreed with the Government Office for the region at the outset (see Working together paragraph 8.15)
The initial scoping of the review should identify those who should contribute. Each relevant service should undertake a separate management review of its involvement with the child and family. This should begin as soon as a decision is taken to proceed with a review, or even sooner if case gives rise to concerns within individual organisations.
The aim of management reviews should be to look openly and critically at individual organisations' practices to see whether the case indicates that changes could, and should be made and how those changes will be brought about.
Overview reports
The LSCB should also commission an overview report that brings together and analyses the findings of the various reports from organisations and others, and that makes recommendations for the future. The overview report should be commissioned from a person who is independent of all the agencies and professionals involved.
Overview reports should be produced in accordance with Chapter 8 (paragraph 8.28) of Working together.
On receiving the overview report, the LSCB should:
- ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report
- translate recommendations into an action plan that should be signed up to at senior level by each of the organisations that need to be involved
- clarify to whom the report, or any part of it, should be made available
- disseminate report or key findings and provide feedback to staff, family members and media as appropriate
- send anonymised copies of the overview report, multi-agency action plan, individual management reports and executive summary to Ofsted, the relevant GO Children and Learner Team and the DCSF.
Contact information
Copies of fully anonymised SCR reports (including the executive summary and overview report, multi-agency action plans, and individual management reports) should be sent to:
- The National Business Unit (NBU) at Ofsted
Their address is: National Business Unit, 3rd Floor, Royal Exchange Buildings, St Ann's Square, Manchester M2 7LA. They can be contacted by telephone on 08456 40 40 40.
- Child Protection Division at DCSF
Their address is: Child Protection Division, The Department for Children, Schools and Families, 1st Floor, Sanctuary Buildings, Great Smith Street, London SW1P 3BT.
- Government Offices Children and Learner Teams who will supply individual local authorities and LSCBs with their regional contact information.
Resources and further information
On 19 February 2008, the Parliamentary Under Secretary of State for Children, Young People and Families, Kevin Brennan MP, wrote a letter to all directors of Children's Services in England and to chairs of LSCBs to emphasise the importance of acting on the findings of two research reports published on 31 January 2008: Improving safeguarding practice: A study of serious case reviews 2001-2003 and Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003-2005.
Associated documents
Improving Safeguarding Practice final SCR
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Last updated on 28/04/2009
