Standing Serious Case Review Panel Terms of Reference and Procedures

Standing Serious Case Review Panel Terms of Reference and Procedures


Powys LSCB Standing Serious Case review Panel sits under the Stay-safe outcome: Safe from significant harm. Panel members sit on Powys LSCB Audit and Policy Group, which also operates under this stay-safe outcome and considers all issues of concern from LSCB contributor agencies. The Audit and Policy Group has separate terms of reference.

The purpose of a Serious Case review is to

·  Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children

·  Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence.

·  Improve inter-agency working and better safeguard children and

·  Identify examples of good practice.

Terms of Reference; Standing Serious Case Review Panel


To meet, as and when required, in order to consider whether, a recommendation should be made to the Chair of Powys LSCB, for a Serious Case Review to be undertaken; To make this recommendation, where appropriate and to provide the reasons for doing so.

To oversee “near miss” cases and conduct reviews which do not meet “Working Together” guidance for a full Serious Case Review and to conduct individual agency reviews or small scale audits of individual cases which give rise to concern but which do not meet the criteria for a full case review.

In the event that a Serious Case Review is undertaken, to be responsible for ensuring that an independent Chair and overview report writer, is commissioned and to ensure that processes are followed in a timely way.

In the event of a Serious Case Review, to ensure learning is disseminated to all LSCB contributor agencies.

Where other reviews are held which do not meet the “Working Together” Guidance for a full Serious Case Review, to ensure that learning is disseminated to LSCB contributor agencies.


Head of Children’s Services, Stay safe lead (Chair)

Superintendent, Dyfed-Powys Police, Stay-safe lead

Named Nurse Child Protection Powys LHB

Safeguarding Manager

Social Inclusion Manager

Designated Doctor Child Protection NPHS

Designated Nurse Child Protection NPHS

Serious Case review Process

·  The Chair and vice chair of Powys LSCB to be informed of the serious injury or death of a child as soon as possible and within 24 hours of the event.

·  LSCB chair refers case to the Standing Serious Case Review Panel which will be convened as soon as possible and within one month of a case coming to the attention of the LSCB chair.

·  At this first meeting of the SCR panel which is convened for the explicit purpose of considering whether a SCR should be recommended in respect of a specific case, the panel will decide who should chair the panel. The chair should be operationally independent of the services being reviewed and must not be the Chair of the LSCB.

·  Panel chair informs LSCB Chair of the recommendation for a Serious Case Review to be undertaken.

·  LSCB chair informs the lead member responsible for Children’s Services about the serious injury or death of a child and proposals to convene a SCR.

·  The Head of Children’s Services to inform the Welsh Assembly Government of the proposed SCR with a brief outline of the circumstances of the case.

·  A discussion with the Welsh Assembly Government agrees a timescale for completion. This includes agreement about extending the timescale if necessary.

·  The Head of Children’s Services to inform the Welsh Assembly Government of any case brought to the attention of the LSCB Chair, that is referred to panel

·  All agency records are secured as soon as the LSCB Chair is told about the serious injury or death and has referred the case to the standing SCR panel.

·  Panel determines written Terms of Reference at the outset of the review that are case specific and approved explicitly by the chair of the LSCB and ratified by the next meeting of the LSCB. These Terms of Reference are specific to the circumstances of the case, are formally evaluated throughout the process of the review and amended as appropriate to take account of new information.

·  An overview author is identified when the Terms of Reference have been agreed. References and safeguarding checks are completed when using an independent person.

·  Funding for the Serious Case Review to be sought from the LSCB.

·  Panel to identify where there may be public interest in a review and to develop media strategies to manage public interest at the outset and at the conclusion of a review. Guidance to be sought from contributor agencies communications advisors in developing media strategies.

·  An early decision is taken regarding the contribution of family members to the review. There is clarity about why the family are asked to make a contribution.

·  The involvement of family members is secured appropriately and involves direct discussion/offer of discussion with the overview author and chair of the panel.

·  Panel to consider the management of the review where criminal investigations are concurrent to ensure there is no delay in identifying learning.

·  A clear strategy is agreed with criminal justice agencies for the management of the review process when criminal proceedings are involved. This includes the Coroners office.

·  The panel will work to procedures to guide the work of the panel. This includes managing the timescales where other processes are involved including SUDI, mental health and homicide reviews and/or where criminal investigations are likely or where complex abuse is involved.

·  Procedures for the conduct of the SCR panel identify arrangements for complaints raised by professionals or the public regarding the handling of specific cases.

Individual Management Reviews

·  Agencies identify appropriately experienced personnel who complete their Individual Management Reviews without delay. Agencies avoid using managers who are responsible for the service being examined. Individual Management Reviews are conducted by a professional with sufficient experience, knowledge and capacity to provide a review which is sufficiently challenging and clear in the account of events and analysing them to provide good learning for the agency and contributing to inter-agency policy and practice.

·  Protocols and information sharing arrangements are in place within Powys LSCB which ensure that all relevant agency records can be examined.

·  Agency reviews look openly and critically at individual and organisational practice. They provide a clear, comprehensive account about the agency’s involvement with a child and their family.

·  The quality of analysis is good and includes reference to identifying why action was taken or decisions made and reflects on whether opportunities were missed to act differently. The Individual Management Review indicates clearly the changes that could and should be made and identifies how the changes will be brought about. There is clear focus on how the agency sought to safeguard the child. The analysis provided within the IMR identifies the learning to emerge.

·  The senior officer in the agency commissioning the report, formally accepts agency review reports and confirms that the review is completed to a satisfactory standard. The agency review will be conducted to required standards and be quality assured. The senior officer for each agency is responsible for ensuring this process is followed.

·  Each Individual Management Review is concluded with SMART recommendations which are linked to the analysis and learning. A clear Action plan demonstrates who will be responsible for ensuring that recommendations are acted upon. Agency reviews identify and distinguish learning in relation to agency resources, policy and training. They reflect on the extent to which agency practice and decision making is sensitive to keeping children safe.

·  IMR’s identify learning and cross cutting development where appropriate for other services including adult services and adult mental health.

·  Upon completion of the agency review report, there is a process for feedback and de-briefing for staff involved, in advance of the overview report being signed off as complete by the LSCB.

·  There are clear arrangements for sharing learning with practitioners and line managers not directly involved in the SCR.

·  Written protocols within each LSCB contributor agency describe clearly how SCR’s are not a part of any disciplinary process or enquiry. The procedures describe what action should be taken if information that emerges in the course of a SCR which may indicate that disciplinary action should be taken under established procedures or that, in the case of regulatory matters, action should be taken by CSSIW.

Overview Report

·  An overview author with appropriate qualifications, knowledge and experience is identified who is independent of the services involved or the LSCB, from the outset of the Serious Case Review.

·  A draft report is presented to a meeting of the LSCB within six months of the Chair formally deciding a SCR is to be completed.

·  The report complies with guidance in “Safeguarding Children: Working Together Under The Children Act 2004”

·  The report provides a factual and comprehensive account of agency involvement, provides good analysis that draws on relevant guidance and research evidence, summarises the learning, including missed opportunities, is frank about the quality of practice, decision making and the review process itself.

·  The report provides SMART recommendations, which can be implemented and evaluated, that are linked to analysis and learning in the report and prioritise the most important lessons and areas for improvement The recommendations are explicit about intended outcomes for children.

·  The overview report routinely examines previous case reviews by Powys LSCB and analyses the extent to which the learning from previous reviews have contributed to the subsequent case.

·  The overview report identifies examples of good practice that go beyond complying with national standards or legal requirements.

·  The overview report explicitly addresses the quality of the review process and identifies where additional support is required from the LSCB and whether there are issues for national policy

Action on receiving the overview report

·  The overview report author presents the completed overview report to the LSCB together with the chair of the SCR panel.

·  Copies of the report are circulated in confidence, prior to the meeting to allow time for prior reading.

·  There is an explicit communication and media strategy describing how the report will be communicated that takes account of the extent and nature of public interest in the case. Professional media expertise is provided to this meeting of the LSCB from the County Council Communications unit to provide advice and support.

·  This meeting of the LSCB considers what briefing will be provided to councillors/MP/Assembly members/Ministers as appropriate, agency board members and de-briefing staff involved in the case and identifies who will complete these tasks.

·  An Executive summary is published that communicates the learning identified and provides a clear account about the action taken to address this.

·  A copy of the Executive summary is made available to the family including a post review meeting if appropriate/requested.

·  A composite action plan is completed against recommendations from IMR’s and the Overview report. The Action plan identifies the named person responsible for completing the action; It establishes a date for completion and the arrangements for reporting to the LSCB against the intended outcomes and provides evidence to support judgements.

·  The LSCB ensures arrangements are in place to disseminate learning from SCR’s. This includes ensuring training strategies reflect the learning and ensuring that subsequent SCR’s include reference to previous reviews.

·  The LSCB identifies the evidence it needs to show continuous improvement in the quality and consistency of multi-disciplinary working.

·  The LSCB has evidence from its own work, the work of member agencies and from other partnerships to demonstrate how safeguarding children and young people is improving. The SCR Panel will audit Action Plans resulting from a SCR, following completion of the review.


All Wales Child Protection Procedures

Safeguarding childen: Working Together Under the Children Act 2004

Serious Case Review Self Evaluation Tool (SCRSET)