Transcript Document
SERIOUS CASE
REVIEW PROCEDURE
NICKY BROWNJOHN
DESIGNATED NURSE FOR SAFEGUARDING CHILDREN
SEPTEMBER 2009
HOW MANY MORE?
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
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
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.
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
INDIVIDUAL RESPONSIBILITIES
Report incidents to line manager / safeguarding lead
Cooperate with review
Reflect on involvement
Seek support / supervision
Contribute to organisational learning
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
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
BSCB RESPONSIBILITIES
Coordinate review
Ensure independence
Involve family
Set action plan
Monitor actions
Challenge non compliant agencies
Support ‘no blame’ culture of change
‘NEAR MISSES’
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’
‘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
MORE THAN TICKING BOXES