RESTRICTED ON COMPLETION – NOT TO BE DISTRIBUTED OR REPRODUCED WITHOUT THE PERMISSION OF BwD SAFEGUARDING UNIT

Referral Form for Consideration of a Case Review

Referrers’ Details

Name: / Designation: / Agency: / Contact Details (email, address and telephone number):

Subject Person(s) Details

Name: / DOB: / Date of Incident: / Gender: / Ethnicity:
Current Address:
Past Address(es):

Family and Significant Others

Name: / Relationship to subject person: / DOB: / Address:

Known Service Provision (subject and family/carers) – please note that this includes local and out of authority services

Children’s Social Care Adult Social Care

Police GP

Specify the GP’s Name and

Address

Housing Education

Specify Service(s) Specify Service(s)

Community Health Services Acute Health Service

Specify Service(s) Specify Service(s)

Mental Health Service Drug/Alcohol Services

Specify Service(s) Specify Service(s)

Probation Voluntary/Private Sector

Provider(s)

Specify Service(s)

Direct Payment

/Personal Budget Service(s)

Specify Service(s)

Please outline the circumstances of the incident (death, serious injury, referral to protective services due to serious harm). Include in this section detail of any internal review or single agency investigation being undertaken as a result of the incident.

Please outline a brief chronological explanation of your agency’s involvement with the subject, parents/carers and significant others. Please include your agency’s involvement/ lack of involvement with other relevant agencies in relation to the service provision/events. Please set out the facts by person and then chronological order.

Please indicate the type of review your agency feels is appropriate (please use the criteria defined in pages 4 to 5 to select the appropriate review and provide your reasoning on page 5):

Child Serious Case Review/ Safeguarding Adults Review

Safeguarding Unit led Multi-Agency Concise Review

Individual Agency Internal Review (reporting to the Safeguarding Unit)

Please tick the appropriate box below that outlines the criteria for the particular review being requested:

Child Serious Case Review

A child dies (including death by suspected suicide) and abuse or neglect is known or suspected

A child has been seriously harmed[1] and abuse or neglect is known or suspected and there is cause for concern as to the way in which the local authority, their Board partners or other relevant persons have worked together to safeguard the child

A child has died in custody (in police custody; on remand; In a Young Offender Institution; In a secure training centre; In a secure children’s home), or when detained under the Mental Health Act 1983, or when a 16-17 year old was the subject of a deprivation of liberty (DoLs) under the Mental Capacity Act 2005

Safeguarding Adults Reviews

An adult with care and support needs (whether or not the local authority has been meeting any of those needs) has died and abuse or neglect[2] is known or suspected to have resulted in the death and there is reasonable cause for concern about how the LSAB, members of the LSAB, or other persons with relevant functions, worked together to safeguard the adult

An adult with care and support needs (whether or not the local authority has been meeting any of those needs) is known or suspected to have experienced serious[3] abuse or neglect and there is reasonable cause for concern about how the LSAB, members of the LSAB, or other persons with relevant functions, worked together to safeguard the adult

The LSAB, members of the LSAB, or other persons with relevant functions agree to review a case where an adult has care and support needs (whether or not the local authority has been meeting any of those needs) with the aim to learn from the case as it is likely to have useful insights into the way organisations work together to prevent and reduce abuse and neglect of adults, or the case has examples of good practice where it is likely to identify lessons that can be applied to future cases

Multi-Agency Concise Review

Where the subject is a child(ren):

A child is harmed through abuse/neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard the child that could lead to significant and new learning that improves multi-agency communication, procedures, policy and/or practice

Where the subject is an adult:

A adult with care and support needs (whether or not the local authority has been meeting any of those needs) is known or suspected to have experienced harm through abuse/neglect and either there is reasonable cause for concern about how the LSAB, members of the LSAB, or other persons with relevant functions, worked together to safeguard the adult the case or the case is likely to have useful insights into the way organisations work together to prevent and reduce abuse and neglect of adults

Individual Agency Review (for both adult and child cases):

Where one or more agencies are concerned in a case and identify failings within a single agency communication, procedures, policy, training or practice that require review and future improvement (this will only be where the child or adult has been harmed – any cases of death or serious harm/abuse or neglect will always be referred for SCR/SAR respectively)

Please outline your reasoning for the type of review requested:

COMPLETED REFERRAL FORMS TO BE EMAILED TO: or

Decision of the Panel (for completion by the Safeguarding Unit)

Date of meeting/discussion:
Decision:
Reasons for decision:

1

[1] Paragraph 4.17 of Working Together to Safeguard Children (2015) defines when a child is considered to have been seriously harmed

[2] Paragraph 14.17 of Care and Support Statutory Guidance (2014) defines the different types of abuse or neglect

[3] Paragraph 14.134 of Care and Support Statutory Guidance (2014) defines when an adult is considered to have suffered serious abuse or neglect