Serious Case Review Quality Markers
Where there are parallel processes the SCR is managed to avoid as much as possible duplication of effort, prejudice to criminal trials, unnecessary delay and confusion for staff and families.
SCRs are often conducted in parallel with criminal, civil or regulatory investigations and human resources (HR) procedures. Other reviews may also be conducted at the same time, such as domestic homicide reviews, mental health independent investigations (ref below) and safeguarding adult reviews. There may be complaints or civil litigation. When a child has died there will be a coroner’s Inquest. There may be proceedings in the family court in relation to surviving children.
These reviews and investigations have distinct purposes and some are the subject of separate statutory guidance. This means they are not all mutually compatible. No process is inherently more important nor therefore automatically takes precedence, however judges in civil and criminal proceedings may make orders that impact on the SCR.
So when they overlap and interact it can cause difficulties and tensions. There are some protocols agreed between key agencies (see below), however they commonly leave much to the discretion of involved individuals. The interactions therefore need to be managed carefully and take into account the importance of:
- SCRs being completed without unnecessary delay
- not interfering unnecessarily in other investigations or prejudicing their outcome
- minimising duplication of effort and expense
- involved professionals and families understanding the role of different reviews and investigations
- enabling the reviews to inform one another where that is consistent with their process.
How might you know if you are meeting this quality marker?
- Is there consideration of any parallel processes in the terms of reference/scoping document?
- Is there an early discussion between the police/ Crown Prosecution Service (CPS) and the SCR and where necessary a face-to-face meeting?
- Is notification made to the coroner at an early point when a child has died and a review is being conducted?
- Is there correspondence between all the relevant reviews showing efforts to achieve the best fit for the circumstances?
- Are notes of interviews and meetings and copies of reports that might be considered relevant to criminal proceedings retained?
- Does the business unit have an index of material generated by the SCR which might be disclosable?
- Is it clear who owns these documents so that the relevant body can make judgements on their disclosure?
- Does the final report acknowledge any interaction with other reviews and any impact on the SCR?
- Practice experience of negotiating interaction between parallel processes when conducting SCRs suggests this is a complex area that can create significant challenges to the SCR.
Link to statutory guidance & inspection criteria
- NHS England ‘Serious incident framework’ (2015).
- ‘Guidance for coroners and Local Safeguarding Children Boards on the supply of information concerning the death of children’ (Ministry of Justice, 2010).
- ‘Liaison and information exchange’ (National Policing Homicide Working Group 2014).
- CPS/Association of Directors of Children’s Services (ADCS) ‘Protocol and good practice model’ (2013).
Tackling some common obstacles
- Early discussion with the police is helpful as views of police officers, the CPS and prosecuting counsel vary as to the constraints that should be placed on SCRs and their willingness to negotiate.
- As the range of parallel investigations and reviews is large and the circumstances of individual cases vary greatly, solutions have to be developed by the LSCB without clear precedent or experience to draw on.
- There is discretion in the SCR methodology that can cause uncertainty for those conducting other reviews, which is why early discussion is helpful.