Chapter 4: Learning and improvement framework

1.

Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.

2.

These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong.

3.

Local Safeguarding Children Boards (LSCBs) should maintain a local learning and improvement framework which is shared across local organisations who work with children and families. This framework should enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result.

4.

Each local framework should support the work of the LSCB and their partners so that:

• reviews are conducted regularly, not only on cases which meet statutory criteria, but also on other cases which can provide useful insights into the way organisations are working together to safeguard and protect the welfare of children and that this learning is actively shared with relevant agencies;
• reviews look at what happened in a case, and why, and what action will be taken to learn from the review findings;
• action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and
• there is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of Serious Case Reviews (SCRs) with the public.

5.

The local framework should cover the full range of reviews and audits which are aimed at driving improvements to safeguard and promote the welfare of children. Some of these reviews (i.e. SCRs and child death reviews) are required under legislation. It is important that LSCBs understand the criteria for determining whether a statutory review is required and always conduct those reviews when necessary.

6.

LSCBs should also conduct reviews of cases which do not meet the criteria for an SCR, but which can provide valuable lessons about how organisations are working together to safeguard and promote the welfare of children. Although not required by statute these reviews are important for highlighting good practice as well as identifying improvements which need to be made to local services. Such reviews may be conducted either by a single organisation or by a number of organisations working together. LSCBs should follow the principles in this guidance when conducting these reviews.

7.

Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.

8.

The different types of review include:

• Serious Case Review for every case where abuse or neglect is known or suspected and either:
  • a child dies; or
  • a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child;
• child death review (see chapter 5): a review of all child deaths;
• review of a child protection incident which falls below the threshold for an SCR; and
• review or audit of practice in one or more agencies.

9.

Where the LSCB has a secure establishment within their area this improvement activity should include an annual review of the use of restraint within that establishment and a report of findings to the Youth Justice Board.

Principles for learning and improvement

10.

The following principles should be applied by LSCBs and their partner organisations to all reviews:

• there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice;
• the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
• reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
• professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;

• families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process;[49]

• final reports of SCRs must be published, including the LSCB's response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections; and
• improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children.

[49] British Association for the Study and Prevention of Child Abuse and Neglect in Family involvement in case reviews, BASPCAN, for further information on involving families in reviews.

11.

SCRs and other case reviews should be conducted in a way which:

• recognises the complex circumstances in which professionals work together to safeguard children;
• seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
• seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
• is transparent about the way data is collected and analysed; and
• makes use of relevant research and case evidence to inform the findings.

12.

LSCBs may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro.[50]

[50] The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011).

Notifiable Incidents

13.

A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

• a child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
• a child has been seriously harmed and abuse or neglect is known or suspected;[51]
• a looked after child has died (including cases where abuse or neglect is not known or suspected); or
• a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).[52]

[51] See paragraph 17 below.
[52] Regulated settings and services: Childcare on domestic premises; Childcare on non-domestic premises; Home childcarer; Childminder; Children’s Homes (including secure children’s homes); Adoption Support Agencies; Voluntary Adoption Agencies; Independent Fostering agencies; Residential Family Centres and Holiday Schemes for Disabled Children.

14.

The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCB or LSCBs promptly, and within five working days of becoming aware that the incident has occurred.[53]

[53] For example, in the case of out of area placements where the placing authority is different from where the child’s care home is based.

15.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

16.

Contact details and notification forms for notifying incidents to Ofsted are available on Ofsted’s website.

Serious Case Reviews

17.

“Seriously harmed” in the context of paragraph 18 below and regulation 5(2)(b)(ii) above includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

• a potentially life-threatening injury;
• serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

18.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCB must commission an SCR.

19.

In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

20.

The final decision on whether to conduct an SCR rests with the LSCB Chair. LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review. The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCB will also want to review instances of good practice and consider how these can be shared and embedded. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

National panel of independent experts on Serious Case Reviews

21.

Since 2013 there has been a national panel of independent experts to advise LSCBs about the initiation and publication of SCRs. The role of the panel is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel also reports to the Government their views of how the SCR system is working.

22.

The panel's remit includes advising LSCBs about:

• application of the SCR criteria;
• appointment of reviewers; and
• publication of SCR reports.

23.

LSCBs should have regard to the panel’s advice when deciding whether or not to initiate an SCR, when appointing reviewers and when considering publication of SCR reports. LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of SCR reports and invitations to attend meetings.[54]

[54] In doing so LSCBs will be exercising their powers under Regulation 5(3) of the Local Safeguarding Children Board Regulations 2006 which states that ‘an LSCB may also engage in any other activity that facilitates, or is conducive to, the achievement of its objective’.

24.

The text which follows provides a checklist for LSCBs on how to manage the SCR process.