SERIOUS CASE REVIEW PROCEDURE

1. SERIOUS CASE REVIEW PROCEDURE NICKY BROWNJOHN DESIGNATED NURSE FOR SAFEGUARDING CHILDREN SEPTEMBER 2009

2. HOW MANY MORE?

3. WORKING TOGETHER TO SAFEGUARD CHILDREN CHAPTER 8 • Ofsted evaluations • Not reflective of self assessments / inspections / JAR • Media attention – professional blame • Always same learning – how useful?? • Too distant from coal face • Lack of transparency • Inconsistent with related processes • Reviewed Chapter 8 – consultation until October 2009 (ECM website) to improve process

4. DEFINITION • When a child dies, and abuse or neglect is known or suspected to be a factor in the death, the first priority of local organisations should be to consider immediately whether there are other children at risk of harm who require safeguarding. Thereafter, organisations should consider whether there are any lessons to be learnt about the ways in which they work individually and together to safeguard and promote the welfare of children. • When a child dies and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a serious case review into the involvement with the child and family of organisations and professionals. Serious injuries due to abuse or neglect • Concerns about inter-agency working to protect children

5. PURPOSE • Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • Identify clearly what those lessons are both within and between agencies, • How they will be acted on, and • What is expected to change as a result; and • As a consequence improve intra and inter-agency working and better safeguard and promote the welfare of children. • Serious case reviews are not inquiries into how a child died or who is culpable. That is a matter for Coroners and criminal courts, respectively, to determine as appropriate.

6. PROCESS • Integrated chronology • Identify critical points • Set terms of reference and focus of review • Single agency review • Multi agency overview • Working together to change of practice

7. INDIVIDUAL RESPONSIBILITIES • Report incidents to line manager / safeguarding lead • Cooperate with review • Reflect on involvement • Seek support / supervision • Contribute to organisational learning

8. MANAGERIAL RESPONSIBILITIES • Report incidents to safeguarding lead • Locate and secure records • Identify support needs of staff • Support arrangements for staff to be interviewed • Accept recommendations • Take ownership of action plan • Reporting mechanisms

9. ORGANISATION RESPONSIBILITIES • Ensure reporting mechanisms in place for SCRS and interlinked processes • Culture for immediate learning and action • Transparency • Support timescales • Ratification of reports • Monitor action plan • Contribution to BSCB work

10. BSCB RESPONSIBILITIES • Coordinate review • Ensure independence • Involve family • Set action plan • Monitor actions • Challenge non compliant agencies • Support ‘no blame’ culture of change

11. Individual responsibilities - follow procedures - report problems Agency leadership - resources - accountability - challenge Resolving professional difficulties protocol - Professional challenge - Constructive debate - No blame culture Quality standards - multi agency sub committee of BSCB - consider working together issues - audit cases referred in by any practitioner - identify key learning - policies and procedures review -BSCB Executive Committee ‘NEAR MISSES’

12. ‘NEAR MISSES’ ‘Waiting for an incident to happen before systems are reviewed can be too late’ SCIE 2008 • Definition of a near miss - something could have gone wrong but was prevented - something did go wrong but no serious harm was caused • Continual learning - integrated audit process - identify good practice

13. MORE THAN TICKING BOXES