APPENDIX 2 - EXEMPLARS

Performance Management Locality Groups
INITIAL CHILD PROTECTION CONFERENCE MONITORING SHEET
AREA…………………………
CHILD / FAMILY NAME:                                          SOCIAL WORKER:             

                                                                                    TEAM MANAGER:              
INDEPENDENT REVIEWING OFFICER: ……………………………….
DATE OF CONFERENCE:                         WITHIN 15 working days of strategy discussion?
*YES/NO 
DATE INVITATION SENT:                           WITHIN   5 working days?                                     
*YES/NO
DID CONFERENCE OCCUR WITHIN SCHOOL HOLIDAYS?                                             
*YES/NO       

REPORTS AND ATTENDANCE  (* Delete as appropriate)

SUPPORT AND INFORMATION OFFERED OR PROVIDED TO FAMILY

COMMENTS FROM IRO

SERIOUS CASE REVIEWS:

BEST PRACTICE

Updated
February 2007

Contents

1  Background to Review Process

2   Scope of a Serious Case Review

3   Agency Responsibilities

4   Management Reviews - Tasks for Reviewer

5   Interview Format & Recording for a Review

6   Guidance on Compiling Review Chronology          

7   Format for Management Review Report

8   Policy / Guidance on Family Involvement

SERIOUS CASE REVIEW PROCESS

1 Background to Review Process

An LSCB should always consider whether to undertake a case review where a child has sustained a potentially life-threatening injury through abuse or neglect, serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect, and the case gives rise to concerns about the way in which local professionals and services work together to safeguard children.

Any agency or professional may refer such a case to the LSCB Chair if it is believed that there are important lessons for inter-agency working to be learned from the case. In addition, the Secretary of State for Health has powers to demand an inquiry be held into the exercise of social services functions under s81 of the Children Act 1989.

The following questions may help in deciding whether or not a case should be the subject of a case review in circumstances other than when a child dies – a ‘yes’ answer to several of these questions is likely to indicate that a review will yield useful lessons:

1. Was there clear evidence of a risk of significant harm to a child, which was:

• not recognised by agencies or professional in contact with the child or perpetrator
  
  or

• not shared with others or

• not acted upon appropriately?

2. Was the child abused in an institutional setting (e.g. school, nursery, family centre)?

3. Was the child abused while being looked after by the local authority?

4. Does one or more agency or professional consider that its concerns were not taken sufficiently seriously, or acted upon appropriately, by another?

5. Does the case indicate that there may be failings in one or more aspects of the local operation of formal child protection procedures, which go beyond the handling of this case?

6. Was the child’s name on the child protection register or had it been previously on the child protection register?

7. Does the case appear to have implications for a range of agencies and/or professionals?

8. Does the case suggest that the LSCB may need to change its local protocols / procedures

or

9. That protocols and procedures are not adequately being promulgated, understood or acted upon?
   

2 Scope of a Serious Case Review

On the basis of the information available the Serious Case Review Panel will draw up clear terms of reference for the Case Review.  Relevant issues include:

• Identify the most important issues to address in trying to learn from this case.

• Would the features of this case indicate that we should involve an outside expert at any stage.

• Confirm the time period events should be reviewed.

• Confirm which organisations and professionals should contribute to the review (including links with independent professionals of a voluntary organisation, etc.).

• Agree how family members will contribute to the review and who should be responsible for facilitating involvement.

• Confirm whether other parallel investigations are likely to take place, e.g.:

- Independent health investigation;
- Homicide Review;
- YJB Serious Incident Review;
- PPO Investigation;

• Agree how other reviews can be co-ordinated.

• Is there a need to involve organisations or professionals in other LSCB areas?  If so, confirm respective roles and responsibilities.

• Confirm how the review process will take account of any:

- Coroner’s Inquiry;
- Criminal investigations/proceedings;
- Liaison with Coroner/Crown Prosecution Service.

• Confirm the date the process should start and the expected date that the review will be completed.

• Agree how public, family, and media interests will be managed at the onset and throughout the Review.
  

3 Agency Responsibilities

In preparation for a Case Review the agency’s nominated lead officer for child protection should:

1. arrange for all case records relating to individuals with a link to the child or family to be located and secured;

2. ascertain records of Child Protection training in the last three years for members of staff involved;

3. where there is current involvement, make arrangements for access by providing a working copy of records to the reviewer;

4. appoint a suitably qualified senior member of staff to carry out the agency Management Review and assure appropriate administrative and secretarial support, having first established wherever possible that the individuals have not had previous involvement in the management of or practice in relation to the particular case;

5. ensure that the person carrying out the Management Review is familiar with the local guidance;

6. ensure that the person carrying out the Review has been provided with copies of the Case Review guidance to people being interviewed.

4 Management Reviews – Tasks for Reviewer

This is intended as a checklist and is not necessarily sequential.

1. Identify key staff to be interviewed.

2. Advise Service Managers of this process and of the need to release staff and time involved.

3. Obtain all relevant records (staff may need to be provided with exact duplicates if these are working files).

4. Prepare initial draft chronology of events and actions, using format in these guidelines.

5. Brief individual staff members who are to be involved following consultation with senior managers about issues to be addressed.  Interviewees to have the option to access staff support, e.g. colleague or staff representative.

The individual meeting with the staff member will address:

1. purpose of review and terms of reference

2. format and recording arrangements for interviews

3. preparation for interviews and time needed

4. location (e.g. not at normal place of work)

5. release from usual duties to prepare and participate

6. support needs

7. purpose of interview and expectations of interviewee

8. access to record of individual interviews

9. access to chronology

10. access to agency and overview reports

11. possible outcomes/debriefing arrangements

12. confidentiality.

Arrange interviews and confirm in writing, interview format, profile of interviewee format, terms of references and purpose of review.

Collect and read all the relevant documentation which gives the context for the professional handling of the case, e.g. procedures, guidelines.

Forward the chronology to staff to be interviewed to amend for accuracy and detail and to return immediately.

Conduct and record interviews, using format in these guidelines and send transcripts to interviewees as soon as possible to identify issues of actual accuracy and any other amendments they consider appropriate.

Send finalised chronology to nominated lead officer for child protection

Produce agency’s review report in recommended format prescribed in this guidance.

Present Management Review to appropriate lead officer for agency endorsement

With supervisor, ensure appropriate consultation within the agency regarding the content of the report prior to submission to LSCB Serious Case Review Panel.

Debriefing meeting with staff involved.

The following advice from “The Management of Case Reviews” by John Fitzgerald is published by the Bridge Publishing House Ltd, August 2001 and provides useful advice for all review officers.

Any conclusions drawn should take account of the following:

• hindsight can make the picture seem clearer than it was at the time

• if criticism appears necessary, it is essential that the evidence is available to support the comments

• when looking back on a painful case, the suffering of a child can provoke considerable anger in even the most experienced of professionals.  Consequently, it is essential that criticisms are grounded in fact, not anger

• those analysing material and drawing conclusions as part of the process should ask themselves this question: “Had I been handling the case on the basis of the information available at the time (not what I know now) can I say the outcome would have been any different”?

• analysis and conclusions must be based on written evidence recorded at the time events occurred and not on verbal or anecdotal material produced after the event which caused a part 8 case review to be set up.

It is important that those carrying through the review have access to good quality consultation, supervision and support in order to avoid pitfalls outlined above.  Given the pressures involved in carrying through a review, it may be necessary to consider the provision of independent consultation to retain a sharp focus.

5 Interview Format & Recording for a Management  Review

Explain the Purpose of the Review and the Interview

The purpose of the interview:

• is to achieve more understanding of what happened in the case from the individual’s perspective

• is to provide staff closely involved with the opportunity to identify what lessons agencies and practitioners can learn from the case

• is not to apportion blame or make findings of culpability, but staff should be aware that any informationwhich emerges from the review would have to be available in the event of any parallel/subsequentdisciplinary or criminal proceedings should they occur.

Complete the attached profile of the interviewee

Matters to be covered in the interview

Go through the agency chronology of the case with interviewee to check the facts and discuss their specific involvement, exploring the following:

• their knowledge of the history of the case, the child(ren) and the family, prior to the interviewee’s involvement

• interviewee’s specific involvement in the case

• interviewee’s knowledge of child development; knowledge about potential indicators of abuse or neglect, including identifying injuries; understanding of psychological effects of abuse upon a child; role in relation to child protection conferences

• interviewee’s knowledge of their agency’s policy and procedures in relation to child care and protection

• was the interviewee sensitive to the needs of the child(ren) in their work; was there evidence of direct work with the child(ren); when and in what ways were the child(ren)’s wishes and feelings ascertained and considered; was the information recorded?

• what methods did the interviewee use to relate to and communicate with other professionals in the case?

• in the interviewee’s record keeping

• what were the key relevant points/opportunities for assessment and decision-making in this case in relation to the child(ren) and family; do assessments and decisions appear to have been reached in an informed and professional way at the appropriate point?

• did actions accord with assessments and decisions made; were appropriate services offered/available/provided, or relevant enquiries made in the light of assessments?

• was practice sensitive to the racial, cultural, linguistic and religious identity of the child(ren) and the family?

• were relevant child protection or care plans in place and the child protection and/or looked after reviewing processes complied with?

• were more senior managers or other agencies and professionals involved at points where they should have been?

• was the member of staff familiar with the agency’s and LSCB policy and procedures for safeguarding children and was their work consistent with these and with wider professional standards?

• what supervision did the interviewee receive; did it address the interviewee’s practice and feelings about the case?

• the range of training available to the interviewee both within and outside the agency in the last two years

• looking back, would the individual do anything differently; can the agency and other agencies learn lessons from the experience; what lessons can the individual learn from the experience?

Record of the Interview

Arrangements should be made to do at least one of the following:

1. tape record the interview

2. have a minute taker present to take notes

3. the interviewer to take contemporaneous notes

During the interview, the record of difficult, complex or contentious issues should be checked back with the interviewee.

After the interview, a detailed account of the interview should be produced speedily.

A copy should be sent immediately to the interviewee for their comments on accuracy and, if possible, for their agreement on content; where the interviewee disagrees, the particulars should be noted and included in the record of the interview.

PROFILE OF INTERVIEWEE

6. The * Family: Multi-Agency Practice Review Recording System

You are asked to adopt the computer based recording system described below.  The attached proforma is a paper copy of the proposed format for the Chronology required within the terms of reference set by Durham LSCB.

Using Word for the chronological record

The figure below depicts the Word document proforma to illustrate how information is entered:

Open the Word programme in the normal way
Click the File icon and select Open icon on the standard toolbar
Click on the filename * Chronology.doc and click OK

The table created for you in Word has 6 columns as shown below.  It has a virtually limitless number of rows in each column.  To create a row click in the end column and press the Tab key.

Remember you don’t have to input the information in chronological order; you may enter it in the order in which it is available to you.

It is highly advisable to save your work regularly to avoid the frustration of ‘lost’ work.

Saving work

It is advisable to save your work under a new file name.  In this way you know exactly how to retrieve your work, and the original blank proforma remains untouched for further use.

Click File on the menu bar, top left of the screen
Click Save As on the drop down menu
Click the (A:) drive option
Type in the chosen file name (no more than 8 characters, and no spaces)
Write the given file name on the disk label.

Correct spelling and typing mistakes

Having saved the materials:

Click on Tools on the menu bar
Click on Spelling and Grammar on the drop down menu bar
Follow the instructions for each word highlighted
Select Change those which need changing and ignore the rest

Printing a copy

To print out a paper copy click File on the menu bar.  Highlight print on the drop-down menu, click on OK on the print menu which appears.  If you need multiple copies set the required amount on the Number of copies box. If you want only that part of the whole record currently on the screen click on Current Page option on the print menu.

Finishing the work

When you have finished entering text into the Chronology ensure that they are saved on a disk which you keep and save a second copy of each record on a second disk, using the new file names given by you.  Print out two copies, one for you and one to send with the disk containing the new files to:

Emma Maynard, LSCB Admin Co-ordinator, Durham LSCB, County Hall, Durham, DH1 5UG.

Lessons from experience

Please adhere to the following ‘rules’, otherwise it makes it very difficult to compile the overall chronological record when individual agency records are brought together.

1. Please don’t change the width of any of the columns.

2. Please don’t remove or add columns.

3. Please don’t change the font or font size in use on the masters.

4. Please label each paper record and computer file clearly to aid recognition by others.

5. If you use initials in the spreadsheet, please add in the space at the top the full name of each person against their initials to ease subsequent identification.

If you encounter IT problems please don't hesitate to contact:
Emma Maynard by telephone 0191 383 3830 or e-mail e.maynard@durham.gov.uk. 
Any other queries please contact myself on 0191 383 3323 or e-mail suzanne.welsh@durham.gov.uk .

7. FORMAT FOR MANAGEMENT REVIEW REPORT

STRICTLY CONFIDENTIAL

SERIOUS CASE REVIEW

(Insert Name of Child)

MANAGEMENT REVIEW REPORT OF:

(Insert Name of Agency)

AUTHOR:        (Insert Name)
(Insert Post)
(Insert Address)
(Insert Tel. No.)
(Insert Date)

Introduction

Reason for the Review

Terms of Reference

Basis of this Report

• list of staff interviewed

• list of files/documents examined

• any staff/files not available and reasons

Production of this Report

• brief details of the author

• brief details about agency on whose behalf the work has been undertaken

• brief details of process for the Review

• supervision arrangements

• consultation/approval process for the agency prior to submission to Investigation Sub-Committee

Family Information

Family Background and Genogram

Summary of Family Background and Circumstances

Analysis of Involvement

Consider the events that occurred, the decisions made, and the actions taken or not.  Where judgements were made on actions taken that indicate management could be improved, try to get an understanding not only of what happened but why.  Consider specifically:

• were practitioners sensitive to the needs of the children in their work, knowledgeable about child development and vulnerability issues and what to do if they had concerns?

• did the agency have in place policies and procedures for safeguarding children and acting on concerns for their welfare?

• what were the key points/opportunities for assessment and decision making and did assessment/decisions appear to have been reached in an informed and professional way?

• did actions accord with assessment and decisions made?

• were appropriate services offered/provided on the basis of assessments?

• if appropriate were child protection or care plans in place with evidence of compliance with reviewing processes?

• were the child(ren)’s wishes and feelings ascertained and was this information recorded?

• was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?

• is there evidence of appropriate supervision/case management?

• was service provisions linked to capacity issues/resources?

• was the work consistent with agency / LSCB policy and procedures?

4. What can we Learn?

Are there lessons from the family for the way in which this agency works to safeguard children and promote their welfare?  Is there good practice to highlight as well as ways in which practice can be improved?  Are there implications for future work:  training (single and inter-agency); management and supervision; working in partnership; resources.

5. Recommendations for Action

What action should be taken by whom and when?  What outcomes should these actions bring about and how will the agency review whether they have been achieved?

6. Sign, Print Name and Date the Report

7. Appendices

Chronology of events in family and agency involvement

Profile of staff interviewed

Interview transcripts

8. Family Involvement in Serious Case Reviews

Background Papers:

• Working Together to Safeguard Children, (1999), Chapter 8

• Learning from Past Experience – A Review of Serious Case Reviews, (2002)

• In the Public Interest Publication of Local Authority Inquiry Reports  The Law Commission (July 2004)

• Getting it Right Solace Guidance on the conduct of effective and fair ad hoc inquiries

Suggested Policy Statement:

When planning and conducting a Serious Case Review, the Serious Case Review Panel must always consider the degree to which family members can be involved in the process. There will be a presumption that family members will be invited to contribute as fully as possible to the Serious Case Review process unless there are reasons to exclude or limit their participation. The degree to which family members are involved will be considered at the first meeting and reviewed at all subsequent meetings of the Panel. The complex nature of a number of interlocking processes (criminal / coronial / disciplinary and possibly litigation processes) make it essential that legal advice is sought as part of the process of defining Terms of Reference.

Defining the family:

• The ‘family’ of a child/ren who are the subject of a Serious Case Review should be identified. Members should not necessarily be limited to those with Parental Responsibility or blood relatives.

• It may be possible / necessary to involve some family members and exclude others.

Suggested checklist of limiting factors, (to be considered at each meeting of the Serious Case Review Panel)

• Where there is criminal investigation or prosecution, and a family member may be responsible for abuse, that person should not be consulted or give information directly to the Panel until the investigation / prosecution is concluded as their involvement may prejudice the investigation / prosecution. If a family member was a witness to the incident / abuse they should not be involved.
  

• Additionally, exclusion should apply to anyone where there is reason to believe may have allegiance to a suspect or perpetrator and may be tempted to disclose to them information gleaned from the process prior to the finalising of an investigation or trial. Any involvement of perpetrator or witness in a Serious Case Review that does occur must be reported to the Police / CPS. It is recordable and potentially discloseable.

• Where involvement is likely to complicate any Children Act proceedings and / or put children at risk.

• The family may have a potential claim against one or more of the agencies. Sharing information may assist or make this more likely. The insurance company may have a view against sharing information

• There may be particular reasons that will make it exceptionally difficult for family members to respond positively to involvement in the Review due to anger or distress which may impede professional exploration of the issues.

• Staff involved may be unwilling to share information freely / as freely if non-professionals are included in the process. This may be a particular issue where staff are continuing to work with the family.

• Preserving confidentiality will become more difficult as the range of those included is widened.

The Serious Case Review Panelmust consider, and keep under review, the degree to which family members should be involved. Each stage could include steps above it. There are legal implications for each of the levels of involvement, but the last four steps give rise to the greatest risk of litigation, either from the family, the child or professionals identifiable from the Review report. Update / progress reports to agencies insurers and CPS at stages throughout the process is strongly recommended and mandatory when options 7 – 10 below are being considered.

1. Provide support to the family from agencies as appropriate / requested from the start

2. Tell the family that the agencies will investigate what has happened

3. Inform the family that a Serious Case Review is to be undertaken and explain the purpose and process

4. Return to the family at intervals to inform them of progress

5. Request information from the family on their perspective of what has happened

6. Provide opportunity for the family to contribute written or verbal views to the review

7. Share content of Executive Summary with family

8. Give copy of the Executive Summary to the family

9. Overview Report to be shared with the family

10. Overview Report to be given to the family

At the conclusion of a Serious Case Review, the Panel should always consider what on-going support family members may need and seek to provide appropriate services from relevant agencies / organisations