Case Management Review

Process Practice Guidance

This document is the property of

Safeguarding Board for Northern Ireland

and must not be copied or used without their prior consent

SUMMARY SHEET

Title: / SBNI CMR Policy and Procedures Practice Guidance
Purpose: / Procedures outlined within this document.
Author: / Sub-group Case Management Review Panel
Ownership: / Safeguarding Board for Northern Ireland
Committee Responsible: / Case Management Review Panel / Approval Date:
Links: / All Member Agencies, SBNI Committees and Panels
Publication Date: / Next Review: / As required or every 3 years after approval date
Version No: / Authorisation: / Date:
0.1 / M. Burke (Professional Officer) / June 13
0.2 / Margaret Burke Professional Officer – comment from Director and CMRP Chair / July 13
0.3 / Margaret Burke Professional Officer – comments from sub-group / December 13
0.4 / Margaret Burke Professional Officer – comments from Director / January 14
0.5 / Margaret BurkeProfessional Officer / January 14
0.6 / Margaret BurkeProfessional Officer / September 14
0.7 / Margaret BurkeProfessional Officer / November 14
0.8 / Margaret BurkeProfessional Officer / December 14
0.9 / Sharon Beattie, SBNI Director / May 2015
0.10 / SBNI Chair and CMRP Chair / May 2015
0.11 / Margaret Burke Professional Officer / May 2015

Case Management Review Process Practice Guidance

  1. Introduction
  2. Context of Case Management Reviews
  3. Notification of a case for consideration of a Case Management Review
  4. Criteria for Notification
  5. Notification Process

a)Cases known to more than one Agency

b)Cases of Good Practice

3.3Documentation required

3.4Nominated Agency Representative link with SBNI

3.5After Nomination received by SBNI

3.6Role of the Safeguarding Panel CMR Sub-committee

  1. Role of the Case Management Review Panel
  2. Role of the Case Management Review Panel Chair
  3. Role of SBNI
  4. Role of the SBNI Chair in Notifying the Decision to Undertake a CMR
  5. Case Management Review Team Chair
  6. Appointment/Commissioning of Independent CMR Team Chair
  7. Contract with CMR Team Chairs
  8. Appointment/Commissioning of Independent CMR Team Chair
  9. Development of the Terms of Reference and Case Plan
  10. Review process and Involvement of Agencies
  11. Interface with other processes (SAI, Coroner, Police, Health & Safety Executive)
  12. Parental/Carer/Guardian/Child(ren) Involvement
  13. Report and Executive Summary
  14. Action Planning Process
  15. Quality assurance process
  16. Presentation to SBNI Board
  17. Publication and Media Handling
  18. Publication of the CMR Executive Summary
  19. ActionPlan Review and Monitoring
  20. Dissemination of Learning
  21. Records Management and Retention

Appendices

  1. CMR Process Map
  2. CMR Action Plan Monitoring process Map
  3. Notification Form
  4. Is Agency Known Form
  5. Guidance for completing Notification Form
  6. CMR Panel Standing Orders
  7. Roles and Responsibilities of Independent CMR Chair
  8. Commissioning Meeting Agenda with CMR Team Chair
  9. CMR Case Plan
  10. Guidance for completion of Individual Agency Review Report
  11. Chronology Template
  12. Proposed Timescales
  13. Template for CMR Report
  14. Template for Executive Summary

Case Management Review Process Practice Guidance

  1. Introduction

1.1The purpose of this document is to provide practice guidance on the process of conducting Case Management Reviews (CMR) under the auspices of the Safeguarding Board for Northern Ireland (SBNI). This document is intended to:

  • help Member Agencies understand how the CMR process works;
  • assist Member Agencies to know in what circumstances to refer cases to the SBNI;
  • ensure consistency in the CMR process across Member Agencies;
  • reinforce the learning dimension of CMRs;
  • provide a step by step guide as to the process involved in undertaking a CMR;
  • outline responsibilities at each stage of the CMR process.
  1. Context of Case Management Reviews

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2.1Regulation 17 of the Safeguarding Board for Northern Ireland (SBNI) 2011 Regulations requires the SBNI to undertake CMRsin accordance with the CMR guidance as laid out in Annex B of the Department of Health, Social Services and Public Safety (DHSSPS) Guidance to the Safeguarding Board for Northern Ireland (SBNI) (Amended May 2014)[1].

The purpose of a CMRis to strengthen the child protection system and to keep children safer. Whilst a review may reflect on the practice of individual professionals involved in a case, its primary focus is on interagency and multidisciplinary systems and processes.

The principles which underpin the CMR process include:-

  • An emphasis on regional and multi-agency learning:

-by identifying what has worked well and then build upon it;

-understanding what has not worked well and why, and how this should be prevented in the future;

-disseminating that learning for the purpose of improving practice and ultimately future safeguarding outcomes for children and young people;

  • Openness and transparency;
  • Achieving objectivity whilst encouraging organisations to be reflective.

The focus of a CMRis on:

  • establishing the facts of the case;
  • identifying what has worked well so that Member Agencies of the SBNI can build upon it;
  • asserting if there are lessons to be learned from the case about the way in which professionals and statutory and/or voluntary agencies work together to safeguard children;
  • identifying clearly what those lessons are, how they will be acted upon and what is expected to change as a consequence;

The CMR will consist of:

 An Independent Overview Report highlighting the lessons learned and identifying any recommendations for future action to strengthen systems for supporting families and protecting childrenin the future;
 An Executive Summary which provides a summary of the case and the learning gained; and
  • An Action Planfor agencies and the SBNI designed to take forward the recommendations and learning from the Review.

The process should be undertaken within the timescales outlined at Appendix 12.

  1. Notification of aCase for Consideration of a Case Management Review

3

3.1Criteria for Notification

A notification for a potential CMR must always be completedwhere a child has died or has been significantly harmedand when any of the following apply:

  1. Abuse or neglect ofthe child is known or suspected;
  2. The child or a sibling of the child is, or has been, on the Child Protection Register (CPR), and is subject to a plan to safeguard that child from further harm and promote his health and development; or
  3. The child, or a sibling of the child, is or has been Looked After by an authority within the meaning of Article 25 of The Children (Northern Ireland) Order.

At least one of the points 1 – 3 must be satisfied for the requirement of a childto be notified. (For full information please refer to Annex B of the DHSSPS SBNI Guidance amended May 2014 referred to previously).

The only legal definition of what constitutes significant harm is outlined in The Children (NI) Order 1995. This threshold is applied in relation to other processes such as the placing of a child’s name on the CPR or an application to Court in relation to the care and protection of children. It is not expected that a notification to the SBNI, for a CMR to be considered, will be based on this same threshold used in these other processes.

As a guide a notificationfor a potential CMR may be considered in any of the following situations:

  1. Where a child sustains life threatening injuries as a result of suspected or confirmed abuse or neglect.
  2. Significant harm includes where there is clear evidence of risk of significant harm that was not acted upon, or not recognised, or shared with others.
  3. When a child dies or is seriously injured whilst in police custody, on remand or following sentencing in the Juvenile Justice Centre, in a Secure Training Centre, or where the child was detained under The Mental Health (Northern Ireland)Order 1986;
  4. Where a child has died by suspected suicide and there are concerns about the effectiveness of safeguarding;
  5. Where a child has been seriously harmed due to a violent and/or sexual assault perpetrated by another child or adult (this includes interpersonal violence, sexually abusive and sexually violent behaviours, fire setting behaviour or arson);
  6. Where a child has been subjected to sexual abuse and/or been sexually exploited where there is evidence that the agency/agencies did not act appropriately together to protect/safeguard the child;
  7. Wherea child’s parent has been murdered, and a domestic homicide review is being initiated. (This process is being developed in Northern Ireland).

If clarity is needed about whether a case meets the criteria for CMR notification, then the Agency[2] should present this case at their local Safeguarding PanelCase Management Review Sub-Committee for discussion. However, ultimately the responsibility for whether to make a notification rests with the Agency initiating the discussion.

3.2Notification Process

Any SBNI Member Agencyor other organisation can refer a case to the SBNI on the basis of the criteria outlined in Section 3.1 for consideration to be given to hold a CMR. Notifications to SBNI must be received two weeks prior to each CMR Panel meeting to be considered at the next scheduled Panel. CMR Panel meetings ordinarily take place on the first Thursday of each month.

It is the responsibility of each Agency to determine whether and at what point, the criteria for notification of a casehas been met. Each Agency must develop a mechanism to enable them to make a timely determination about whether the criteria for notification are met. Advice can be sought from SBNI Officers to assist with queries relating towhether mandatory criteria for notification are met. This advice should help the Agency with its decision whether or not to make a notification.

a)Cases known to more than one Agency

If more than one Agency is involved, a discussion between the agencies should take place and if possible agreement reached about the need to notify the SBNI of the case and which Agency should complete the notification. This would be included as part of the mechanism each Agency must develop to enable them to make a timely determination about whether the criteria for notification of a potential CMRare met. If no agreement is reached, the Agency who initiated the discussion should still proceed and make a referral to the SBNI if they believe the criteria outlined in Section 3.1 has been met. Agencies may wish to consider referring the matter to the Safeguarding Panel’s Case Management ReviewSub-Committeeto assist with the decision as to whether or not a case meets the criteria for referral to the SBNI.

Once a Member Agency determinesthat the criteria for a CMR notification is met the matter should be referred to the SBNI without delay.

Cases can also be notified to the SBNI via the Coroner, the Northern Ireland Commissioner for Children and Young People, the Court Service of Northern Ireland,the Northern Ireland Guardian Ad Litem Agency, any regulatory or inspection body,and any other statutory or voluntary organisation not cited in the Regulations, who believe that a case meets the criteria for consideration of a CMR[3]. The Child Death Overview Panel (CDOP) (when established) may also notifya case to the SBNIfor consideration of a CMR. (Likewise the CMR Panel can also notify a case to CDOP if a case is felt not to meet the criteria for a CMR).

The SBNI may receive requests/concerns from members of the public to hold a CMR in individual cases. In accordance with legislation SBNI do not accept notifications from individual members of the public;however the SBNI will refer the matter to the lead Member Agency to consider whether the case meets the criteria for notification to the SBNI for a Case Management Review.

b)Cases of Good Practice

The Board is currently finalising the process in regards to identifying and reviewing cases which satisfy Regulation 17(3) relating to positive learning.

3.3Documentation required

To assist the SBNI CMRPanel in its deliberations as to whether or not a recommendation should be made for a CMR to be held, the Notification Formshould becompleted(Appendix 3, attachment - Please refer to Appendix 5 for guidance on how to complete the form). This should beaccompanied by a short Briefing Report completed by the notifying Agency setting out the reasons and circumstances for the Notification being made. The most recent contemporaneous comprehensive assessment report, if any,which gives an overview of the case and relevant background information, should also be forwarded along with the Notification Form. A list of appropriate reports is outlined in the Notification Form.

3.4Nominated Agency Representative link with SBNI

Each Member Agency must nominate a Senior Representative at the level of Assistant Director or equivalent, who has the authority to make decisions on behalf of their Agency, to act as the key contact for SBNI in relation to the CMR process including completion and signing of the Notification Form. Member Agencies will be asked to confirm this nomination annually.

3.5After Notification is received by SBNI

Once a notification has been received the SBNI willacknowledge this in writing. If it is felt that additional information is required, the SBNI will request samefrom the notifying Agency.

The SBNI will inform all appointed representatives on the CMRPanelin writing that a notificationhas been received. Agency or Sector representatives on the CMR Panel will berequested toclarify whether or not the child and/or family is known to their respective agencies using the ‘Is Agency Known Form’ (Appendix4). Each CMR Panel Member should then ensure that their Agency’s databases are checked to gather this information. In relation to Health and Social Care Trusts this should include information systems for both health and social care. If the child and/or family are known the appointed representative on the Panel should ensure a brief chronology/details of the Agency’s involvement and relevant information is submitted in writing to the SBNI Officers using the template provided (Appendix 4), for the attention of the CMRPanelin advance of the CMR Panel meeting. This information will be sent by the SBNI Office to CMRPanel Members prior to the CMRPanel Meeting.

3.6Role of the Safeguarding Panel CMR Sub-committee

If it is unclear whether a case meets the criteria for a CMR, the case can be discussed at the Safeguarding Panel Case Management Review Sub-Committee who willadvise on whether or not the notification meets the criteria for notification. However, it ultimately the responsibility of the initial Agency which initiated the discussion to make a decision about whether to notify a case or not.

The Sub-committee also has a role in reviewing and monitoringlocal recommendations made in completed reviews, the Action Plans arising, and report back to the Safeguarding Panel on progress.

4Role ofthe Case Management Review Panel

4.1The CMR Panel’s roleis as follows:

[to] consider whether the criteria for undertaking a CMR as set out in Regulation 17 of the SBNI Guidance(amended May 2014),are met as follows:

17 (2)‘a child has died or has been significantly harmed (including where there is clear evidence of risk of significant harm that was not acted upon, ornot recognised, or shared with others) and when any of the following apply and one of the following apply:-

(i) Abuse or neglect ofthe child is known or suspected;

(ii)The child or a sibling of the child is or has been on the child protection register and is subject to a plan to safeguard that child from further harm and promote his health and development; or

(iii)The child or a sibling of the child is or has been looked after by an authority within the meaning of Article 25 of the Children (Northern Ireland) Order.

And

(c)The SBNI has concerns about the effectiveness in safeguarding and promoting the welfare of childrenof any of the persons or bodies represented on the Safeguarding Board by virtue of section 1(2)(b) and (4)of the Act.

(d) The Safeguarding Board determines that there is significant learning to be gained from the case management review which, if applied effectively, will lead to substantial improvements in practice in safeguarding and promoting the welfare of children in Northern Ireland

As stated in the SBNI Guidance (amended May 2014) all four strands of Regulation 17(2) [(a), (c) and (d) and at least one element of (b)] must be satisfied for the requirement for a CMR to be triggered, that is, in circumstances where a child has died or been significantly harmed.

It is proposed that the term ‘significant’ and ‘substantial’ are understood as meaning that the learning to be gained from a review of a case is:

-relevant to current processes and systems for safeguarding and promoting the welfare and protection of children;

-likely to be useful given the changes in legislation, policies, systems and practices over time;

-currently applicable to children and families living in similar situations to the child(ren) under review;

-likely to add to the knowledge already existing about the relevant issues in a case;

-likely to lead to changes that will make a positive difference in how children are protected in Northern Ireland.

Criteria 2(d) does not place a time bar on whether cases of a historical nature should be notified to the SBNI. This means, that, should any Agency or Body deem that the criteria for a notification has been met, then that body should make a notification.

In addition the SBNI has a role for identifying and disseminating good practice as set out in Regulation 17 of the SBNI Guidance (amended May 2014):

(3) The SBNI will also consider taking forward a CMR in cases that demonstrate effective working (individually or in partnership) of persons or agencies who are Members of the SBNI and where there is outstanding positive learning to be gained from the case which would lead to improved practice in safeguarding and promoting the welfare of children in Northern Ireland.

4.2Other responsibilities of the CMR Panel

The CMR Panel has a number of functions that flow from their role in advising the Board about whether a CMR should be initiated. These are to:

-make a recommendation as to whether or not a CMR should be held on the basis of whether Panel Members feel that the criteria has been met;

-determine whether further information is required from the notifying organisation to assist with that consideration if required;

-highlight particular areas/issues that should be included in the Terms of Reference for a CMR and determine draft Terms of Reference;