Serious Case Review Quality Markers
The Serious Case Review (SCR) gains sufficient information to underpin an analysis of the case in the context of normal working practices and relevant organisational factors.
The purpose of an SCR is to learn from past professional practice to support improvements in future safeguarding. This requires an analysis that evaluates and explains professional practice in the case, shedding light on routine challenges and constraints to practitioner efforts to safeguard children. The organisational factors that helped and hindered timely help to families and protection of children need to be ascertained. This requires a wide range of information types to be gathered including:
- The facts of what happened in the case – who did what, and when?
- The rationale for decision-making, action and inaction – why did people do what they did, what were they trying to achieve, what was influencing their practice?
- How normal was their behaviour – is this the way things are usually done?
The sources of such information are varied including:
- formal records, paper-based and electronic
- practitioners and managers who were involved in the case or potentially should have been
- senior managers and leaders responsible for strategy and its operationalisation
- the child(ren), young people and family members as well as friends and community where relevant and appropriate
- documents that explain how services were then or are currently provided (procedures, policy documents, audits, inspection reports etc.)
- ICT systems and processes used.
A range of different techniques exist through which to engage with these different types of information and make best use of what they can provide.
What is a sufficient amount of information will vary. All reviews aim to be proportionate, which means that different reviews will require different amounts of information assembled to achieve their aims. Different commissioners and different models vary in how much they aim to clarify whether any problematic practice identified in the case was more widespread at the time. Similarly, only some models set out to assess the current relevance of past practice issues identified in the case being reviewed. Information needs may also change as the analysis progresses.
How might you know if you are meeting this quality marker?
- Has there been discussion about what information needs to be requested and what level of detail is required, relative to decision-making about the proportionality and other commissioning specifications of the review?
- Has guidance been provided to LSCB members about what information is requested at the beginning of the review, and the level of detail required, and why?
- Have all potential sources of relevant information been considered?
- Has access been arranged for the lead reviewer(s) and relevant others to all the different sources of information deemed relevant?
- Are the methods being proposed for assembling the information appropriate to the nature of the different information sources and the commissioning specification of the SCR?
- Does the structure of the SCR enable direct input by practitioners and managers (e.g. interviews, group meetings)?
- Is there transparency about any reasons for non-cooperation by LSCB members?
- Using a range of types of information, including softer data such as the views and experiences of those involved, is an established principle of effective investigation across domains. This is supported by practice experience of conducting SCRs.
- Recent Department for Education (DfE) commissioned research into barriers and facilitators to learning supports practitioners’ involvement in SCRs as improving learning (Rawlingsetal., 2014).
Link to statutory guidance & inspection criteria
- Para 11, p 74 of ‘Working together’ (HM Government 2015) provides details about how SCRs and other case reviews should be conducted.
Tackling some common obstacles
- Moving beyond individual errors in practice to understand systemic problems means that it is not necessary to examine every aspect of practice in equal depth.
- Understanding exactly the form and focus of the SCR that has been commissioned and the rationale will help people to understand the type and amount of information being requested.
- Expertise in research methods can help in generating the right type of data from the different sources.
- Heightened group work skills are often needed to minimise the risk of harm being done through engaging with staff.
- Where there is consensus about the need for an SCR, member agencies’ contribution to the review is improved.
- Clarity about whether information is gathered for the purpose of the SCR or to enable individual agency learning supports open engagement.
- Flexibility about the best means of obtaining practitioners’ views can help address the issue of staff movement (e.g. using Skype for interviews if a professional has moved abroad).
- People can be inhibited from sharing information if they think that to do so would have negative consequences, this is best addressed by developing a culture of learning from mistakes without blame.
- Agreeing governance arrangements for cases that cross multiple borders helps with enabling access to all necessary information.