National Guidance for Child Protection Committees for Conducting a Significant Case Review

Considerations to be made by CPC following a decision that an SCR is appropriate

Methodology

CPCs should always consider and agree the methodology to be used in undertaking the SCR. Evidence-based methodologies to consider are:

Systems approaches

A systems approach focuses on learning about how local professionals and organisations work together, in order to improve inter-agency working and better safeguard and promote the welfare of children and young people. The model has been adapted from the systems approach used in other high-risk areas of work and supports analysis that goes beyond identifying what happened to explain why it did so. The central idea of the systems approach is that any worker's performance is a result of their own skill and knowledge and the organisational setting in which they are working.

The SCIE Learning Together model

The Social Care Institute for Excellence (SCIE) Learning Together^[7] approach has been designed specifically to be relevant to cases involving multi-agency working by

• using systems thinking to gain a deeper understanding of current local practice and cultivate an open, learning culture
• building internal capacity by having staff trained and accredited in the Learning Together approach to reviewing
• undertaking rigorous case reviews and audits using a core set of principles and analytical tools
• accessing a pool of accredited independent reviewers as required
• building on the experience and findings of previous reviews as part of the Learning Together community.

For those conducting an SCR using this methodology, there will be no specific recommendations. Instead, the CPC will have findings and issues to consider.

The Learning Together^[8] model was developed by SCIE, based on evidence from research literature and investigation methods used in engineering, health and social care.

A SCIE training programme familiarises reviewers with the Learning Together process and analytic tools. An accreditation process for lead reviewers assures basic competence. Thereafter, lead reviewer expertise is supported through supervision and regular participation in the Learning Together community of practice.

The model has three key principles:

1. Avoid hindsight bias by understanding how the case unfolded from the viewpoint of those involved. This is done by reviewers being open-minded and empathetic and having no preconceived assessment of the case beforehand. The source of information, or data, comes primarily from conversations with the practitioners and family involved and details are supported from documented evidence. The information is collated into a narrative reconstruction of events as they took place using the perceptions and understanding of people who were there at the time. Although the events taken together run chronologically this is very different from a dated chronology taken from case records alone. It forms the local 'rationality'.

2. Provide adequate explanations by appraising practice and explaining decisions and actions taken. This is done by using a specific analytical tool, called 'key practice episodes' (KPE) that helps us understand and explain why the case unfolded as it did. It gives an explicit appraisal of practice, from the perspective of what was known or knowable at the time and identifies the various factors that may have contributed to that. It is a process that holds people to account for their professional responsibilities but which can also point to the kind of things that make those responsibilities very difficult to carry out at times.

3. Move from individual instance to general significance. This allows the case to provide a 'window on the system' (Vincent 2004)^[9] and tease out issues that replicate more widely rather than just being relevant to a single case. This includes the opportunity to expose those hard-to-articulate practices such as cultures and values within organisations that impact on effective working. These are written as evidenced 'findings', which then give rise to issues for the CPC to consider.

The review process aims to include the views of the case group (practitioners directly involved in the case) and the review team (members include managers from the relevant agencies), as well as family members. The model also includes the role of a champion who ensures open communication lines between the CPC and the review process. This role is commonly taken by the lead officer if they are not part of the review team.

(See SCIE website for more information on the detail of the review process and illustrations of how practitioners at different levels are included)^[10].

Root Cause Analysis

Root Cause Analysis (RCA) techniques are used to understand the underlying causes of incidents rather than identifying individual failure. Based on human error theory^[11], the RCA model has been adapted for use in health and social care settings. It takes into account the active failures of frontline staff to follow a prescribed course of action and also considers latent failures, well-intentioned but in hindsight faulty management decisions by senior management, and contributory factors such as staff shortages, poor communication, busy work environment, emotional state of staff member, education and training. As such, this is a system-based approach which seeks not only to clarify the direct actions leading to the accident or incident but the contribution made by the wider organisational context.

Identify who undertakes the review

The CPC will need to consider whether an SCR should be led internally or externally or with some external overview. CPCs need to ensure that the lead reviewer and the review team, between them, have the necessary skills and competencies to undertake an SCR. These skills will differ according to the circumstances of each case and the agreed role of the review team. Annex 3 provides a 'person specification' list for a lead reviewer.

The CPC may decide to appoint an internal lead reviewer if the circumstances of the case, based on the evidence of the ICR, suggest that any recommendations are likely to have mainly local impact. In the case of an internal review the team would probably be drawn mainly from within the CPC's members but CPCs should always consider using external expertise for part of the process in the form of a consultant, professional advisor or critical friend^[12] - a trusted, impartial person whose functions can include reviewing data, providing guidance or challenge and critiquing an individual's work.

The CPC may decide to commission an external lead reviewer if:

• There are likely to be national as well as local recommendations;
• Local recommendations are likely to be multi-agency rather than single agency;
• The case is high profile, or is likely to attract media attention;
• Elected members, NHS Board members and MSPs have voiced their concerns;
• The child's family/carers or significant adults have expressed concerns about the actions of the agencies.

Where an external review is commissioned, the SCR continues to be owned by the CPC. The Chief Officers Group/CPC should agree any formal contractual arrangements that may be required, along with appropriate legal advice. They should consider which agencies will enter into the contract and ensure that individuals have professional indemnity cover. Consideration should be given to involving legal services in drawing up formal contracts covering areas like timescales, fees and confidentiality.

Any contract should also include explicit instructions on the access to, storage of, transport of, transmission of, and disposal of sensitive personal information as required by the Data Protection Act. For the purpose of the SCR, the lead reviewer is a data processor, not a data controller and will not need to be registered with the Information Commissioner's Office (ICO). This is because they are acting on the instructions of the CPC, representing the Chief Officer Group. There is further information on the role and responsibilities of a Data Processor in ICO guidance^[13]. The ICO Data Sharing Code of Practice^[14] details the circumstances where a data sharing agreement or contract may be required. This will be of particular relevance where there are a number of agencies inputting to the SCR.

Regardless of whether the lead reviewer is internal or external, the CPC will wish to set out clear expectations in respect of timescales, milestones in the process and deadlines for completion of reports.

The CPC should notify the Chief Officers Group and all agencies involved in the case that there will be an SCR and that fact should be recorded on the case record and the cases of relevant adults.

Chronology

The CPC will wish to ensure that a multi-agency chronology of significant events and contacts is prepared (this may already have been prepared as part of the ICR process). The chronology should be circulated to agencies and professionals to check for accuracy. GIRFEC practice briefing 8^[15] contains a useful example of a chronology template.

Remit

Depending on the comprehensiveness of the information gathered at the ICR stage it may be possible for the CPC to agree the remit of the full SCR at the initial meeting or immediately afterward. If there are areas that need further clarification the CPC may ask agencies to undertake particular tasks and report back within an agreed timeframe.

In the case of an externally-led review the remit and the key question(s) should be agreed in writing by the chair of the CPC and the external lead reviewer. Regardless of who leads the review, the remit should be agreed by the chief officers.

The clearer the remit the easier it will be to manage people's expectations about the outcomes of the SCR. This applies both to those involved in contributing to the SCR, and to the wider audience. The degree of complexity and the question of who to involve might not become clear until some initial work has been undertaken, especially in the case of an external SCR. Consequently, the remit may need to be reviewed at a later stage. If changes are made, they should be agreed and appropriately documented by the CPC.

The remit should include a deadline for production of reports, taking account of the circumstances and context of the case. Where deadlines have to be extended, for example in circumstances where other proceedings intervene, this should be recorded and a new deadline agreed by the CPC.

The lead reviewer (internal or external) must be briefed by the Chair of the CPC (or person with designated responsibility). The lead reviewer must be given access to the initial reports prepared by agencies for the ICR, to help them identify which agencies need to come to the initial SCR meetings.

The written remit of the review should:

• Be agreed by the CPC. This can be reviewed throughout the SCR process but any changes should be agreed by the CPC and documented;
• Clarify roles and responsibilities across agencies;
• Set the time frame the review will cover; and
• Be clear and deliverable.

Annex 4 gives an example of a remit document which CPCs. It can be adapted to fit with local arrangements and the specific case being considered.

The review team

It is important to establish a team to support the lead reviewer so that agencies feel confident their specialist issues are understood. The CPC should ensure there is sufficient multi-agency representation on the review team in order to reflect the particular case. A review team's different perspectives can add to the depth of enquiry. Training or information requirements for the team should be considered.

The team should be agreed at the outset and agreement reached as to roles and responsibilities, who should undertake tasks such as file reading and interviews, and how disputes will be resolved. No one should be involved in a review team if they were directly involved in the case in a professional capacity.

For any review team, it is important to establish whom the key contacts are in all the agencies involved. These could be designated SCR contacts who can also advise on, and broker access to, relevant practitioners and information. Additionally, they should be able to provide any relevant agency information (such as protocols/guidance) and generally act as a liaison point. In addition, consideration should be given to who will make links with relevant interests outside the main statutory agencies. The team will also need to gather relevant evidence from a wide variety of sources and be prepared to negotiate if information is not forthcoming.

Consideration should be given to the skills required in the review team. This will vary according to the case and agreed responsibilities of the team but CPCs, or mandated sub groups, will wish to consider ensuring that the review team has the following skills:

• A broad knowledge of children's services;
• Investigation skills;
• Analytical and evaluation skills;
• Ability to make sound judgements on information collected;
• Ability to critically analyse all factors that contributed to the significant case and the wider impacts for practice and service delivery where appropriate;
• Ability to liaise with others and establish a good working relationship;
• Ability to demonstrate sensitivity to national and local level issues; and
• Appreciation of the need to be clear about the difference between an SCR's remit and task as opposed to other ongoing proceedings relating to the case (for example, a criminal investigation).

A review may reveal staff actions or inactions which are of sufficient seriousness that they need to be brought to the attention of the employer. The review team has a duty to do this, irrespective of the SCR process.

Resources

The National Child Protection Guidance for Scotland (2014) says that Chief Officers have a collective responsibility to ensure their CPC has the resources, including staff time and finances, to fulfil its roles and responsibilities. Conducting an SCR falls within this area of responsibility. Chief officers should, therefore, agree how the review team will be financed and how its expenditure will be managed.

Administrative support should also be agreed, as should practicalities such as accommodation, secure storage of any records shared, and secure access to electronic records.

The report

It is important that there is a degree of consistency in the structure and content of SCR reports to make it easier for people to identify and use the findings, and for read-across to other reports to be made. The report should, therefore, include the areas outlined in Annex 5.

CPCs will wish to consider arrangements for correcting factual errors or misunderstandings in drafts of the report.

The lead reviewer will present the final report (and executive summary) to the SCR review team before it is sent to the CPC chair for consideration by the CPC. This includes both internally- and externally-commissioned reports. The CPC should deliver the report to the Chief Officers Group. The CPC may ask the lead reviewer to present the report at the Chief Officers/CPC meetings.

Freedom of information and data protection

The CPC should ensure that the review team and lead reviewer take account of the requirements of the Freedom of Information (Scotland) Act 2002 and the Data Protection Act 1998 in both the conduct and reporting of the review. The Scottish Information Commissioner's decisions^{[16] [17]} in relation to the release of SCRs also highlight issues for consideration. Annex 6 contains an extract from an SCR which may be helpful in considering the report structure and content in respect of the Data Protection Act 1998. However, the circumstances of each case will be different and particular consideration should be given to the requirements of the Data Protection Act 1998 on each occasion. Arrangements should be put in place for secure storage and filing of confidential information and files. These arrangements should also include retention schedules and processes for destruction of the information when it is no longer necessary to hold. These details can be included in data sharing agreements. NHS will wish to seek Caldicott approval in respect of access to any patient files where this is required by the lead reviewer as part of the review process.

Involvement of the child/young person/family/carers

The family/carers of the child or young person should be kept informed of the various stages of the review as well as the outcomes where appropriate. There will be occasions where the child/young person/family/carers could be subject to investigation or have otherwise triggered the SCR. In these cases, information may need to be restricted. Close collaboration with Police Scotland, the Procurator Fiscal, and possibly SCRA will be vital.

There may also be cases where families are considering taking legal action against an agency or agencies that are the subject of the SCR. Individual agencies' complaints procedures should be made available to the family at the outset of their involvement with the family, and throughout any SCR investigation, as deemed necessary and appropriate. This is not the responsibility of the CPC or of the review team.

Every effort should be made to involve children/young people/families/carers. SCR reports should say whether or not the child or young person and families/carers were informed and involved. If not, they should record a reason. If they were involved, reports should record the nature of the involvement and document how their views have been represented. Diversity issues should be considered and adequate support should be provided to ensure that a child or young person, family/carers are able to participate.

Care should be taken about where and when a child/young person, or their family/carers are interviewed, and if any special measures are needed to support this (for example, the use of advocacy or interpreter services, with particular care given to those with impaired communication). In particular if there are, or are likely to be, criminal proceedings or if there is, or likely to be a fatal accident inquiry, the review team must consult with the local COPFS, police and/or SCRA prior to any interviews. Reviewers should be experienced in communicating with children and young people.

It may also be useful to assign a member of staff as a single point of contact for the child/young person/family/carer throughout the review. CPCs will wish to consider whether it is preferable for this person not to be involved in the SCR process. The person carrying out this liaison role should be fully aware of the sensitivities and background of the case. This person's role could include advising the family of the intention to carry out an SCR and making arrangements to interview the child, family/carers or significant adults involved. Any briefing would normally be an oral discussion.

Depending on the particular case and sensitivities, consideration should be given to arrangements for feedback to the family. This may also include what how they can input to check the accuracy of what is recorded in the interim and/or final report.

Support for staff involved in a review

During the review process staff who have been involved in the case should feel informed and supported by their managers. There may be parallel processes running (such as disciplinary proceedings) as well as the SCR so sensitive handling is important.

Each organisation should have its own procedures in place for supporting staff, but the following should always be considered:

• The health and wellbeing of staff involved;
• Provision of welfare or counselling support;
• Communications with staff and keeping people informed of the process in an open and transparent way;
• Access to legal/professional guidance and support; and
• Time to prepare for interviews and for follow up.

Staff involved in a review should be given this guidance, together with a copy of the local operational protocols in their CPC area. CPCs should consider what mechanism will be used to enable contributors to check the accuracy of what is recorded as it is drafted for the interim and/or final report. When the review is complete, staff involved in the case should be debriefed before the report and findings are published.

Dissemination and publication

For each individual SCR, the CPC - in conjunction with the Chief Officers - should have a dissemination strategy that best serves the public interest and the purpose of improving service delivery. The following points should be considered, depending on the content of the SCR:

Dissemination

• CPCs should agree timing of a local dissemination which involves all agencies and which ensures the spread of any identified good practice as well as learning, particularly to front-line practitioners.
• In order to promote national learning, the findings and recommendations from all SCRs should be shared among CPCs. This should include any good practice identified and should be facilitated through the meeting of the Scottish Child Protection Committee Chairs Forum (SCPCCF) or by specially convened meetings or seminars. SCPCCF should consider what and how recommendations are taken forward at a national level.
• SCRs which include a specific recommendation with national implications should be shared with the relevant organisation and with the Scottish Government
• The Care Inspectorate, on behalf of the Scottish Government, acts as a central collation point for all SCRs carried out by CPCs in Scotland from 1 April 2012. The purpose will be to report regularly on key themes to help all CPCs improve local practices and to support their continuous improvement agenda. This work will include reporting on aspects of good practice and areas for improvement worthy of dissemination nationally.

Publication

• It is for the CPC (with chief officers' approval) to decide whether to publish the full report or just the executive summary. Influencing this decision will be considerations about the need to restore public confidence, protections within the Data Protection Act 1998, sensitivities and balancing interests in terms of the right to respect private and family life detailed in Article 8 of the European Convention on Human Rights. If, for example, the report contains identifiable personal information this should be anonymised before publication. Where the full report is not being published the summary should explain any redactions that have been made. See Annex 4 for an example, and also the section on Freedom of Information and Data Protection.
• The CPC's first responsibility is to report to the chief officers group. But the CPC must also consider the wider reporting requirements and distribution of the report/executive summary. A list of potential organisations and people to whom the report/executive summary can also be sent to is at Annex 7 but it is always for the CPC, in consultation with the chief officers group, to decide this in each individual case.
• It is imperative that the child's right to privacy and the child's right to be protected are at the forefront of all decisions and communication relating to publication of a SCR report.
• Family/carers and/or other significant adults in the child's life should get a copy of any report in advance of publication except if they are subject to any criminal proceedings in respect of the case.
• Publication of the report may need to be delayed until the conclusion of criminal or FAI proceedings. Where criminal, FAI or children's hearings proceedings are ongoing the publication of any report should always be discussed with COPFS and/or SCRA.

Other considerations include:

• Whether an oral briefing for relevant parties in advance of publication is required. This is particularly the case where there is likely to be interest in the case amongst the wider public and may avoid misrepresentation.
• How publishing the SCR report will provide evidence of learning.
• How the findings of the SCR report sit within the wider context of children's services.
• Whether all parties have been informed and their views taken into account (child, family and staff).
• Liaison with COPFS/police/SCRA where criminal proceedings have taken, or are taking, place.
• Whether staff integrity has been respected and duty of care considered.

Media handling

The media can help promote more effective prevention and intervention to protect children and young people by raising public awareness about what can cause harm, and what members of the community can do to mitigate risks.

Any agreed communications strategy should include a media-handling plan. Most agencies will have communications officers for the agency and any protocols/handling issues should be developed in conjunction with them. Before the report is made public, the review team should:

• agree who will link with the media on behalf of chief officers/CPC;
• brief the relevant communications officer(s); and
• approve the wording of any quotes.

No information about an SCR should be released to the media unless it has been approved by chief officers/CPC.

Communication with the media should focus on learning, and point out that the majority of children and young people are protected. It is important not to add to any sense of alarm or confusion and CPCs should proactively offer interviews to the media where this supports their strategic objectives (for example, raising awareness of the process of SCRs or about the role of CPCs).

Once an SCR report is published and in the public domain where possible a high-level spokesperson should respond to media requests.