Learning From Serious
Case Reviews
Prity Patel LLB (Hons)
Independent Consultant
September 2011
Learning Outcomes
• To develop an understanding of the purpose and
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process of conducting a Serious Case Review (SCR)
To gain a better understanding of the Practice Guidance
governing a SCR
To understand key ways of promoting action learning
within the SCR process have knowledge about the
purpose, process and outcomes of serious case reviews
To receive the findings of two local SCRs (Baby F and
Child G) and one Case Audit (Case W) and some
themes from national learning from SCRs
To have the opportunity to discuss how the learning from
these cases should influence inter-, and intra-, agency
working in Bournemouth and Poole
Practice across all agencies will reflect on the learning
from these cases
Working Principles
• Each individual has a valid contribution to make which
will be valued and listened to
• Confidentiality should always be observed
• There will be mutual respect within the group for
individuals and their experiences
• Naive questions will be considered the norm!
Serious Case Review
The Purpose Of A SCR
• Prime purpose for agencies and individuals to learn
lessons to improve the way in which they work both
individually and collectively to safeguard and promote
welfare of children
• Identify clearly what those lessons are both within and
between agencies- What changes in practice need to be
made
• Lessons learned should be disseminated effectively
• Recommendations should be implemented in a timely
manner
Serious Case Review
The Purpose Of A SCR
• Where possible lessons should be acted upon quickly
without necessarily waiting for the SCR to be completed
• SCRs are not inquiries into how a child died or was
harmed or form part of any disciplinary process
Serious Case Review
When To Conduct A SCR?
Working Together sets out the requirement for SCRs
A LSCB should always undertake a SCR:
• When a child dies and abuse or neglect is known or suspected to be
a factor in the death.
A LSCB should consider whether to undertake a SCR:
• 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; or
• A child has been seriously harmed as a result of sexual abuse; or
• A parent has been murdered; or
• A child has been seriously harmed following a violent assault
perpetrated by another child or an adult and there is concern
about how local services were delivered by professionals
involved with the family.
Serious Case Review
SCR Panel
• Ensuring membership of SCR Panel is vital - should
include at least representatives from relevant Partner
agencies. (WT 8.14) Panel will define the scope of the
Terms of Reference for the SCR
• Independent Chair and Overview Author (WT 8.16)
• Health - Designated Leads or Named Nurse for
Safeguarding
• Health Overview Author - required to prepare Health
Overview Report
Serious Case Review
IMR - Preparation
Each agency involved in a case will write their own
Individual Management Review
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Review records and files
Develop initial facts/chronology and analysis
Interview staff- always keep a record. (WT 8.38)
Re-read files
Finalise Chronology and genogram
Finalise Factual Information
Finalise Analysis
Identify the Lessons Learned
Make Recommendations
Serious Case Review
The Purpose Of an IMR
• To look openly and critically at organisational practice
• To identify and analyse the context within which people
were working
• To indicate if the case identifies that improvements could
or should be made
• To identify how those changes can be brought about
Serious Case Review
IMR - Contents
• IMR and chronology is completed using templates from
the LSCB
• Basic details and methodology
• Contextual Background - demographics of population
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you are providing a service for, is there anything
particular to your geographical area that may impact on
how a service is provided or meeting service user’s
needs ?
IMRs and SCRs are anonymised
A factual summary of the agency’s involvement is set out
and analysis of this is undertaken
A genogram and family composition is supplied
Serious Case Review
IMR- Analysis
• Consider decisions made and the actions taken or not
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taken
Consider what best practice should be and how the
service should have been delivered
If practice has changed since the incident that led to the
SCR, this should be outlined
Were judgements made, or actions taken which indicate
that practice or management could be improved?
Gain an understanding of not only what happened but
also why?
Significant learning can be gained from probing beyond
the surface. A good IMR should reflect this
Serious Case Review
IMR - Analysis
• Statements will be corroborated with effective examples
to support your analysis
• Analysis is related to procedures and policies in respect
of your agency and LSCB
• Criticism needs to be constructive
• The Terms of Reference sets out the areas for focus
within the IMR as identified by the SCR Panel and WT
(8.39WT)
Serious Case Review
IMR - Analysis
• The IMR will reference Local and National Professional
Standards/Guidance and learning from previous SCRs
from your LSCB, and the Biennial Analysis of SCRs
• It will flag up Good Practice - Over and beyond what was
necessary to meet the child’s needs NOT what is
expected practice
Serious Case Review
IMR- Recommendations
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Identify Lessons Learned
List Agency Recommendations- Make them SMART
Be succinct!
Focus on a few key areas
Link to Lessons Learned
Recommendations WILL NOT be about what
professionals should already be doing
Serious Case Review
Action Plan
• Action Plan = Actual or Recognised Learning. Identify:
• the action
• who will have lead responsibility within the agency to
ensure action is fully implemented
• the timescale to achieve completion of the
recommendation – Be Realistic but not foolish!
• What will be the desirable outcome
• How can the outcome be evidenced/measured?
• Individual Agency Action Plan will form part of
Composite Action Plan that LSCB will monitor until all
actions completed and can be signed off
• Endorsement by Chief Officers of the agency
Serious Case Review
Timescales
• A SCR to be completed within 6 months (WT 8.23)
• SCR Chair will prepare a timetable
• Important to meet deadlines- Failure to do so impacts
upon the whole SCR process
• OFSTED feedback from previous SCR’s- Delay in
meeting timescales has been a significant factor in poor
Reviews
Serious Case Review
Learning-Feedback
• Learning needs to be implemented and acted upon –
needs to be timely
• Dissemination of Learning- Consideration to be given to
what type and level of information needs to be
disseminated and to whom
• Staff directly involved in the case need to have
feedback, may require support
Serious Case Review
IMR Format
• Summarise the salient points of the key themes that you
have identified in your analysis, including good and poor
practice
• Highlight any progress that has already been made
regarding implementing change in practice
• This will be an opportunity for SCR Panel Members to
raise questions with you- make sure you read your IMR
before presenting it including informing the Panel of any
updating information that may be relevant to the review
Serious Case Review
Presenting the IMR
The SCR Panel scrutinises all the IMRs and will interview
each IMR author at a SCR Panel
• The Panel is an opportunity for SCR Panel members to
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raise questions with the author
It is very likely that the author will be asked to make
amendments and additions to the IMR as the information
from other agencies may indicate gaps or areas to be
explored again
The IMR is re-submitted following this work
Serious Case Review
Outstanding IMR’s
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Comprehensive history and chronology
Good depth of detail/clear family history
Staff/Managers interviewed to support file review
Identification of strengths and good practice
Keeping the child the focus of the IMR
Focussed recommendations linked to the analysis
Clear and SMART action plan which identifies lessons
already learned
Serious Case Review
The Health Overview Report
• To provide a critical overview of all health services
• They will not repeat information already provided in the
Health IMRs – they will identify where there may be gaps
in the analysis which needs to be included to tell the
story from Health’s perspective
• Summarise salient learning points identified in Health
IMRs- Always ask “ Why and so what?”
• Comment upon Health IMR recommendations- identify
gaps if any, make further SMART recommendations if
appropriate
Learning From Serious Case
Reviews
• Last 15 months Bournemouth & Poole Local
Safeguarding Children Board (B&PLSCB) has conducted
several reviews
• 2 SCRs - Baby F and Child G
• 1 Independent Case Review – Case W
• Bournemouth & Poole Adult Safeguarding Board
conducted a SCR May 2008
• Overlap of key learning from both child and adult reviews
involving Professionals from all agencies
Baby F - Background
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Baby F born in summer 2009- Unplanned first baby
Parents 18 and 17 yrs respectively
Parental relationship- known each other 8 months
Mother articulate and engaging with services initially.
Father has a history of CAMHS and YOT history
Incident of abuse when baby F 5 weeks old
MARAC threshold
Father bailed - conditions no contact with mother – baby
not specified
CP Inquiry, no CP Conference
Baby F – Background (cont.)
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Mr A breached bail conditions
Further bruising on mother
CP Conference – emotional category
Father convicted of assault on mother
Bruise to face – aged 4 months – no action
Bruise discussion aged 5 months at Core Group
January 2010 admitted with serious injuries bruising to
face and parts of body, torn fraenulum, 3 fractures to one
leg possible broken legs
Themes From the Case
• Assessment/Planning
• Domestic Violence – impact on children
• Engaging Fathers/Significant Males within the household
• Record keeping
Assessment/Planning
• Quality of assessment impacts on outcomes for the child
• Drawing on historical information
• Child Protection Plans- Need to be SMART (Specific,
Measurable, Achievable, Realistic and Timely) and
robustly monitored
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Include fathers/significant males
Explore parents’ own accounts
Assessment needs to be child focussed at all times
Multi-agency – what information can be collated from
other Professionals
• Assessment needs to have a holistic approach.
Assessment of Injuries
• Know your own agency procedures on seeking medical
opinion
• Timing of medical opinion crucial
• Observation- physical and behavioural
• History taking and reactions
• Rooted in Child development e.g.; non mobile babies
• Appropriate recording - use of Skin Maps
• Referral and further investigation
Domestic Violence
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Cycle of abuse
Impact on child
Deceit / manipulation- disguised co-operation
Reliance on bail conditions and Written Agreements
Protective measures
Contact arrangements- consider supervised or not,
frequency, duration and review
• Recording of injuries to both adult and child, taking a
holistic approach
• Direct questioning. An Investigative style of questioning
needs to be developed. Probe below the surface, do
not take at face value
Engaging Fathers/Significant Males
• Meet with fathers/significant males in as many assessments as
possible
• Don’t let them be invisible!
• May have to make suitable arrangements with working males- Offer
alternative appointments
• Learn about their role in the family- how does it impact upon the
child
• Record their views
• Explore their history
• Understand the strengths they bring to the family and identify the
risks
• Talk to other Professionals
• Consider them in analysis and assessment
Engaging Fathers/Significant
Males(2)
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Fatherhood Research Summary
“…..If professionals systematically gather the young man’s
details by, for instance, routinely asking the mothers for
them in early pregnancy, develop Interagency working
while making child outcomes the focus of their work and
mainstream engagement through the service” ( e.g.
teenage pregnancy service, “While keeping good
records and comprehensively assessing the young
men's needs, substantial numbers of young fathers can
be reached with interventions that make a real
difference…..”
Record Keeping
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Record observations of child, verbal and non-verbal
Records to be child focussed- child’s perspective
Record parents’ account in detail
All recordings must be accurate and evidence based!
Maintaining good records assists reflective Practice
Child G - Background
• SCR conducted following a case of filicide/suicide. Child
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G 6 years old when killed by his father in summer 2010.
Father killed himself at the same time
Coroner’s Inquest makes Finding - Child G unlawfully
killed and Mr G, father, took his own life
Child G living with both parents at time of birth. Parents
separate, at time of death Child G spending considerable
time with both parents
Mother had little previous involvement with services.
Father had significant involvement. He carried out
several suicide attempts and experienced suicidal
ideation over a 30 year period preceding the incident
Father involved with mental health services and GP
Child G Background(2)
• Child G diagnosed with diabetes 3 years prior to incident
• Child G’s parents engage well with appropriate health
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services. There is good liaison between health and
school services. Child G receives support from the local
speech and language service
During acrimonious separation father alleges he
informed mother he wanted to commit suicide
Police called to family home as mother has concerns
about child’s safety, father having taken Child G from
school unexpectedly
Police attend family home. Police judge Child G to be
safe in care of father. Mother also present at family
home. Police treat as a domestic violence incident
Court application made by father. Court adjourns
substantial hearing, further enquiries to be made by
Themes From the Case
• Suicide/Filicide
• Domestic Violence/DV1 Notifications
• The Court Process
• Compliance/Information Sharing
Suicide/Filicide
• Suicide/Filicide very rare
• By it’s nature a deliberate and thought-out act with
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limited research available - impossible to predict
Historic events regarding adult mental health,
significance of these need to be retained and viewed as
a continued risk
Professionals to develop a style of Practice to ask
questions directly of suicide and suicidal intentions
expressed. Critical to any assessment of risk
Parental separation - If suicide threats made, do not
regard as common place, take seriously
Consider implications of suicidal threats on child as part
of any risk assessment
Consider previous triggers
Seek Management advice
Domestic Violence/DV1 Referrals
• Police oversight of DV1 notifications requires a
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knowledge of children’s safeguarding issues
DV1 notifications – A Multi- agency assessment is likely
to lead to a more comprehensive assessment leading to
better outcomes for the child
Role of GP pivotal to identification and management of
potential risk of DV. GP a good source of information
and support for the child/family following a DV incident
The Court Process
• The Private Law Programme (April 2010) at the first
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hearing the Court should consider risk identification and
the impact of any known risk on a child’s welfare
The Court initially is dependent on being informed by
the Officer’s of the Court (CAFCASS reporting officers)
to make appropriate safeguarding enquiries about the
family , highlighting any concerns or risks that the Court
needs to be made aware of
Roles and responsibilities of Court Officers need to be
clear to avoid insufficient attention being given to
assessing risks to a child
The Judiciary need to keep abreast of Safeguarding
Training
Compliance/Information Sharing
• Failure to comply with procedures undermines effective
risk assessment of children
• Organisations have a responsibility to ensure staff are
able to comply with procedures and able to access
necessary training. Needs to be a regular part of
management support and monitoring
• Procedures are less likely to be followed or less
stringently applied potentially leaving children at risk
• Difficulties in communication and sharing of relevant
information between agencies hinders effective risk
assessment
Case Review W- Background
• 3 young people, aged between 14-16 years of age from
the Poole area found guilty of manslaughter. Their
victim, a man sleeping rough in Westbourne in April 2009
• All of the young men were remanded to a Young
Offender Institute (YOI). The trial at Winchester Crown
Court concluded a year after the offence, when all three
accused were found guilty of manslaughter. They are all
due for release in 2011
• All 3 young people and their families known to agencies
due to a number of welfare concerns
• The circumstances of the case did not meet the criteria
for a Serious Case Review
Themes From the Case
• Engagement/Intervention of Agencies
• Professional Judgement/Assessments
• Multi-Agency Working
• Peer Pressure/Anti-Social Behaviour
• Family Issues
• Communications/Information Sharing
• Record Keeping
Engagement/Intervention of
Agencies
• Opportunities for agencies to intervene at early stages
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not consistently taken- missed opportunities
Hard to engage families
Need to work with the families and be more challenging
of information presented to identify risk factors
Need to work together and not in isolation. Assessments
may be conducted, but are not effective if information not
shared with other Professionals
Investigative style needs to be adopted. Do not be too
accepting of responses families give i.e. do not need any
support
Planning required. Exit strategies for young people need
Engagement/Intervention of
Agencies(2)
• Consider the need to have specialist workers
• All Professionals need to be clear about roles and
responsibilities in the plan devised for the young personcould lead to better engagement from families
• Need to understand a young person’s needs. Youth
services play a pivotal role in ensuring there is
appropriate engagement with a young person
• Young person needs to feel empowered for effective
engagement.
Professional
Judgements/Assessments
• Assessments- crucial to take a history from families as
part of risk assessment. Likely to highlight triggers which
inform services and support provided
• Use of the CAF still requires clarity. Professionals need
to know when to use and in what context. Confusion in
use of CAF can lead to lack of appropriate intervention
• The Southwark Judgement( May 2009) obliges
Children's Services to provide accommodation and
support to homeless 16 and 17 year olds.
Multi- Agency Working
• Professionals need to work proactively in a multi-agency
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arena to gain the families’ engagement in order to help
support them in their care of young people
Consider the need for a multi-agency risk assessment.
Can lead to a more coherent and comprehensive
assessment with better outcomes
Multi- agency meetings- Need to ensure all relevant
Professionals attend to increase chances of a robust
multi- agency risk assessment
Collaborative thinking by Professionals required!
Professionals need to follow through on referrals to
Peer Pressure/Anti- Social
Behaviour
• Lack of understanding by agencies including the School,
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Police, Anti Social Behaviour Team and Youth Offending
Team involved with the young people regarding the
escalation in destructive behaviour
DCSF Guidance on working with young people affected
by group anti social behaviour in the community will be
available with relevant risk assessment tool
There was a lack of reference or understanding of the
misuse by young people of alcohol and drugs Substance
abuse was not considered as part of any assessment of
risk
The use of Restorative Justice Procedures could have
been used more broadly with the young people
Family Issues
• Vital to consider all members of the family as part of risk
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assessment including any significant males. All three
boys had difficult family upbringings and appeared to
lack consistent positive male role models
Consider what support networks are in place for the
family, particularly if main carer is a sole carer
All risk assessments need to consider cultural and
literacy issues to inform adequate and appropriate
planning. Failure to do so impacts on outcomes for
young person
Communication
• Communication needs to be clear, concise and requires
the use of simple language. Professionals need to make
sure what they are saying is easily understood. Use of
an interpreter/ translator where English is not the first
language
• Communication needs to occur both inter- and intraagency. Lack of information sharing leads to missed
opportunities
Record Keeping
• Good practice to ensure chronologies/summaries always
reflect the depth of history of the families and the number
of contacts. Need to make sure the information is used
to inform assessments about the “here and now”.
• Ensure records are accurate, evidence based and can
be accessed easily. Important to be able to access
historical records, crucial information may be missed if
not accessed as part of a risk assessment.
Adult SCR Case A- Background
• Mrs A an elderly widowed lady aged 83 years.
• Mrs A murdered by her son-in law in 2008.
• Mrs A’s daughter and son-in-law had a history of mental
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health and known to have a violent relationship. They
were also known to Probation and received considerable
support.
Both moved in and out of Mrs A’s home on several
occasions. It was alleged both were violent and abusive
to Mrs A.
Mrs A told her GP she was frightened of her son- in –law
and stressed by them both.
Referrals had been made by neighbours and a family
member to the Police about concerns for Mrs A’s welfare.
Agencies had information on their records about
concerns for Mrs A, however the information was not
Themes From the Case
• Identification of Safeguarding issues.
• Domestic Violence.
• Communication/Information Sharing.
• Compliance.
Identification of Safeguarding
Issues
• Multi- agency partners need to understand the definition
of a “vulnerable adult”
• Trigger signs need to be recognised by Professionals of
adult abuse
• The same significance needs to be given to a vulnerable
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adult experiencing abuse as a child experiencing abuse.
A holistic approach is required. Looking at the “bigger
picture”
• Multi- agency risk assessment leads to better outcomes
Domestic Violence
• Consider the pattern of DV reported. Look at the
historical information held on records to give context to
DV occurring. Do not look at DV incidents in isolation
• Consider the impact of DV on all persons within the
household even though they may not be a direct
recipient of the DV
• Ensure that the scene of potential violence is safe for the
vulnerable person
Communication/Information
Sharing
• Discuss/contact other Professionals regarding any
referrals or significant information held on your records
where there are safeguarding concerns
• Consider the use of multi- agency meetings to exchange
relevant information
• Lack of communication leads to poor outcomes for
service user. Significant missed opportunities can have
serious consequences
• Ensure all communication is accurately recorded
Compliance
• Failure to follow either your own internal policies and
procedures or local agreed protocols can lead to poor
service delivery
• In order to effectively execute your safeguarding role
and responsibility it is your duty to ensure you are
familiar with relevant inter and intra agency guidance
and Practice locally
Recurring Themes
Clearly there are recurring themes from all reviews
conducted both children and adult matters:
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Assessments
Communication/Information Sharing
Multi- agency working
Compliance
Record Keeping
Making A Difference!
• Why are there recurring themes?
• What can you do inter and intra agency to change your
Practice from today?
• How can you make a real difference?
Making a Difference! (2)
• Good news! - Both B&PSCB and the Adult Safeguarding
Board have already started implementing learning from
reviews conducted
• Combined agency Action Plans with close scrutiny by
relevant Boards regarding progress of each action
identified
• Achieving improved Practice across all agencies in
Bournemouth and Poole areas