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Practitioner involvement

Serious Case Review Quality Markers 

Quality statement

The Serious Case Review (SCR) enables practitioners and managers to have a constructive experience of taking part in the review.


Practitioners and managers who were involved in the case, or potentially should have been involved, are an important source of information for an SCR. Their input is critical to understanding why individuals acted as they did and what was influencing their practice, including routine ways of doing things. How they experience being involved is important. SCRs can be frightening and threatening and employers have a duty of care to all staff, which requires them to provide adequate support. Individual learning is also enhanced by practitioners having a positive experience of contributing to the SCR. The broader learning and improvement culture of an organisation is strengthened by good feedback from practitioners who have been constructively involved in an SCR. Therefore the SCR needs to enable those involved to have a constructive experience of taking part.

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

  1. Is the purpose of any interviews, conversations, meetings or events that involve practitioners clear?
  2. Are participants being provided with clear information about the SCR and their role in it?
  3. Are agencies encouraging their staff to contribute their experiences and views to the SCR?
  4. Does the planning for the SCR include consideration of how to support individual practitioners? For example, those who played key roles in the case, or who are not part of core Local Safeguarding Children Board (LSCB) agencies, or are from agencies rarely involved in SCRs.
  5. Are practitioners being provided with adequate protections within their own organisations?
  6. Are practitioners being provided with adequate support and protection in the planning of any group events?
  7. Has there been adequate consideration of whether there are any implications of the review for people now in senior management positions and if anything needs to be done to support them?
  8. Are there plans to gather feedback from participants about their involvement?

Knowledge base

  • Department for Education (DfE) funded research on SCRs has shown that practitioners welcome the opportunity of being directly involved in SCRs (Rawlingset al., 2014).
  • Lead reviewer experience highlights the dangers of practitioner events that are not clear about purpose and function.
  • Research in the use of root cause analysis in health suggests that staff tend not to participate readily if they don’t think genuine learning will emerge (Nicolini et al., 2011).

Link to statutory guidance & inspection criteria

  • ‘Working Together’ (HM Government 2015) requires that ‘professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith’ (p 73). 

Tackling some common obstacles

  • Where there is clarity about the purpose of practitioner interviews, conversations, meetings and/or events it is easier to manage any tensions for individuals.
  • Participating in a group may be experienced positively but can present some individuals with challenges linked to their role in the case being reviewed, and this needs to be considered and addressed.
  • Where staff have previously had positive experiences of practitioner events it is easier to achieve a constructive experience.
  • The stronger the open learning culture of agencies, the easier it is for senior managers to support practitioners to engage openly in the process.
  • The expertise of the lead reviewer(s) in handling complex group dynamics helps minimise risks associated with group events.
  • Agencies may indicate a formal ‘sign-up’ to the principles of openness but it can be more difficult to achieve full commitment from all managers, and this needs to be considered when planning practitioner events.