1. Wirral Safeguarding Children Board Learning from Case Reviews

2. Contents What are Serious Case Reviews? The SCR Process
Cases below the SCR Threshold
National and Local Learning
Sources of further information

3. 1. What are Serious Case Reviews?
Undertaking SCR’s is a statutory function of LSCB’s
Working Together states a Serious Case Review when:
abuse or neglect of a child is known or suspected; and
(b) either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child
If a case does not reach the threshold for a SCR, but the LSCB can learn from the case then a critical incident or learning review should be undertaken
The final decision about undertaking a SCR is made by the Independent Chair and approved by the National Panel for SCR’s

4. Purpose of Serious Case Reviews
The primary purpose of SCRs….
“…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.”
Source: Working Together to Safeguard Children (HM Government, 2015)

5. National Panel of Independent Experts
Established in 2013 the role of the panel is to support LSCBs in ensuring that appropriate action is taken where the statutory SCR criteria are met and to ensure that lessons learned are shared through publication of final SCR reports. The panel also report to the Government their views of how the SCR system is working through an annual report.
The panel's remit includes advising LSCBs about:
application of the SCR criteria;
appointment of reviewers; and
publication of SCR reports.
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.

6. 2. The SCR process Referring into the SCR Committee
Any professional can refer a case into the case review committee for consideration as a potential SCR
WSCB advise professionals to consult with their manager/ safeguarding lead prior to making a referral
Committee request chronologies if threshold might be reached
SCR Committee meets monthly to consider referrals

7. Decision Making and Role of the SCR Committee
Multi-agency SCR committee oversee SCR process
Wirral SCR process is published in the Learning and Improvement Framework (LIF)
LIF includes referral form, decision making matrix, methodology for appointing reviewer, undertaking review, publishing findings, creating an action plan and ensuring learning
All SCR and CIR activity is reported into the WSCB

8. Cases that meet the threshold for a SCR
SCR committee advises Independent Chair who ratifies (can challenge) the decision
National Panel informed who must approve decision
Once approved an independent author and preferred methodology identified (usually SCIE Learning Together)
Case Review group identified; scope of SCR agreed
Case Review undertaken overseen by SCR committee (aim for 12 months from referral to completion)
Upon completion Case Review report published, actions identified and learning disseminated
Statutory arrangements will change

9. Working Together to Safeguard Children 2015
3. Cases below the SCR Threshold
LSCBs should 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.
Working Together to Safeguard Children 2015

10. Case Reviews - Process
Below the SCR threshold there are 3 levels of case reviews – Critical Incident, Learning and Single Agency
Cases nominated for review are considered against WT2015 criteria by the Case Review Committee
Cases will be reviewed if there is likely to be useful multi-agency or single agency learning
This can be about practice, effectiveness of partnership working, thresholds, unusual or rare cases etc.

11. Case Reviews - Process
Once level of case is decided (process based on SCIE model):
Agencies identified and chronologies and key questions completed
Information analysed and Key Practice Episodes identified
Case Review group established (practitioners and operational managers)
Case Review group meet and consider Key Practice Episodes and draw out learning

12. Case Reviews - Process
Report published including recommendations for the WSCB – WT15 recommends LSCB’s aim for completion within 6 months of case review being initiated
Accepted recommendations used to populate action plan
Performance Committee overseas completion of the action plan
Learning and Development Committee develops strategy to disseminate learning

13. 3. National and Local Learning

14. SCR’s are often very Emotive

15. SCR’s aren’t about finding someone to blame

16. SCR’s are about looking at the ‘system’ to see what needs to change to prevent tragedies happening

17. Safeguarding Board partnerships must learn from SCR’s otherwise practice will not change

18. Learning from the Child G SCR led to the Who’s Looking Out for the Teenagers? Conference and raised awareness about the vulnerabilities of older teenagers, specially those with MLD

19. National Learning - Children
The 2012 DfE report on learning from SCR’s presented the following significant learning points which professionals need to be aware of:
1 in 5 SCR’s is undertaken on a child currently or previously on a child protection plan
About 50% of children are known to children’s social care
36% of all SCR’s are undertaken on babies less than 1 year old (most vulnerable group)

20. National Learning - Children
Teenagers (14-18) are the second most vulnerable group
Neglect is an underlying feature in over 60% of all SCR cases
Poor information sharing and ineffective multi-agency working are a feature of almost all SCR’s

21. National Learning - Families
45% of families had had frequent house moves
53% of families had current or previous domestic abuse
63% had current or previous adult mental health concerns
33% had current or previous substance misuse

22. National Learning - Families
45% had a parent with a criminal conviction
75% of families did not cooperate with agencies
75% of children had lived with at least one of domestic abuse, parental mental ill health or substance abuse – the Toxic Trio

23. National Learning – Toxic Trio
(case study example)

24. National Learning – Messages
Families are often very chaotic and the chaotic behaviour becomes mirrored in professional’s thinking and actions
Often families and professionals are overwhelmed by the number and extend of problems faced by the family
Professionals tend to work in their own agency silo’s and do not see the bigger family picture
Proper supervision and support – particularly regular supervision for staff is missing
Poor parental co-operation is not challenged (and good or sudden engagement masks harm to children)
Poor integrated working and lack of information sharing hides bigger picture from professionals

25. National Learning – 8 Messages to Remember
Maintain a healthy scepticism in working with families and be familiar with disguised compliance
Balance optimism with healthy scepticism
Understand the thresholds and know procedures
Know how to escalate concerns you have
Put yourself in the shoes of the child and see their life from their point of view
Have access to regular supervision/ reflection to gain a different perspective of the case
Be aware of the vulnerabilities of older teenagers
Share information across agencies

26. Local Learning – Case Studies
Child G (handout)
Child CF (handout)

27. Disseminated Learning Examples – all examples are on the WSCB website

28. National Learning is disseminated and on website

29. https://www. wirralsafeguarding. co

30. Local learning

31. https://www. wirralsafeguarding. co

32. Thematic learning

35. 4. Sources of Further Information
WSCB Website:
Website includes case studies, posters, case review reports, learning and thematic learning examples updated quarterly
2. NSPCC Website:

36. End of WSCB Presentation
@wirrallscb