The report

Serious Case Review Quality Markers 

Quality statement

The report clearly identifies the analysis and findings of the Serious Case Review (SCR) that are key to making improvements, while keeping details of the family to a minimum. Findings reflect the explanations for professional practice that the analysis has evidenced.

Rationale

The main function of the report is to make accessible the SCR analysis, in order that it can support necessary improvement work. Descriptions of practice problems are not therefore sufficient. Instead, findings/recommendations need to reflect the explanations of professional practice that the analysis has identified, if learning and improvement are to result. These need to be easily identifiable so others can use them. Making the working-out process transparent helps in evidencing the findings so their validity does not need to be taken on trust. Such a presentation can also increase public accountability and supports public trust.

The Local Safeguarding Children Board (LSCB) also has the statutory responsibility for publishing the report in a format, without redaction, that will not be likely to cause harm to any child or vulnerable adult involved in the case. A key part of this is protecting their privacy. There is often other information on the case in the public arena, for example media coverage and anonymised family court reports.

The information is usually readily accessible via the internet. This makes it difficult to include in the SCR report any personal data or precise identifiers, such as the exact chronic health condition, without the risk that it makes the family identifiable, or reveals personal or sensitive information about them to those who can already identify them. Consequently, personal and sensitive information about family members should not be included and precise details about the case should be minimised. This does not prevent detailed descriptions of professional actions and contexts that are often needed to explain practice problems and evidence findings.

How might you know if you are meeting this quality marker?

1. Does the structure of the report make it straightforward to identify relevant analysis and findings, so as to assist other local areas to identify learning that is pertinent to them and to assist the collation of learning at a national level?
2. Does the amount of information provided in the report satisfy the need for privacy of family members and individual staff while providing sufficient information to make accessible the SCR analysis, in order that it can support necessary improvement work?
3. Does the report contain findings and/or recommendations that reflect the areas deemed as priority for improvement?
4. Do these findings and/or recommendations address explanations of practice or remain only descriptive of issues identified in how professionals handled the case?
5. Is there transparency in how conclusions have been reached?
6. Does the report adequately manage accessibility and explaining complex professional and organisational issues?
7. Is the tone and choice of words appropriate to the review?

Knowledge base

• Learning into Practice Project (LIPP) research on SCR reports (2016) has identified that it is often very difficult to pinpoint ‘analysis and findings’ in SCR reports and that this presents challenges for enabling national learning from individual SCRs.
• LIPP research on SCR reports (2016) notes how common it remains for such reports to remain purely descriptive of the case.
• Ascertaining the effects of the full publication of SCR reports that contain detail about family members and their circumstances on those family members is challenging. For children concerned the effects may occur in the distant future. 

Equality & diversity

• Concern about impact on vulnerable family members of publication.  

Link to statutory guidance & inspection criteria

• ‘Working Together’ (HM Government, 2015: p79) provides guidance about publication. This includes stating that ‘From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case’. It states that final SCR reports should:
  • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence
  • be written in plain English and in a way that can be easily understood by professionals and the public alike
  • be suitable for publication without needing to be amended or redacted.
• The annual reports from the National Panel of Experts provide additional direction about the content of SCR reports. This direction includes stressing that reports 1) capture lessons for the services concerned, that focus on what caused things to happen at critical points in the management of the case; and 2) do not include detail that is not relevant to that learning (e.g.  blow-by-blow accounts of what happened to the child). They also emphasise that reports be succinct and accessible (National Panel of Independent Experts on Serious Case Reviews, 2014, 2015).

Tackling some common obstacles

• Explaining what happened in a case and why, as well as protecting the privacy of family members involved in the case, are two tasks that are somewhat at odds with each other. The more you do of one, the less you can do of the other. Acknowledging this tension can help to address anxieties about whether the report is compliant with statutory requirements.
• The drive to produce SMART recommendations (specific, measurable, achievable, realistic and time-bound) can deter from a full exploration of practice problems that are complex and for which there are no easy solutions.
• Balancing the need for individual confidentiality with providing sufficient information to understand the rationale for changes recommended to professional practice is challenging for lead reviewers. They may be assisted by editorial support.
• Small geographic areas present real challenges to the possibility of anonymising the family if saying anything specific about the case.
• Different, often contradictory, advice exists as to what constitutes a ‘good’ report. Acknowledging this can bring clarity to discussions.
• Open discussion with the lead reviewer about the nature of the final report, as part of the process, helps avoid misunderstandings and repeated rewriting at the final stages of the review.