National guidance for child protection committees undertaking learning reviews

2. Key Features of Learning Reviews

The key features of a Learning Review are:

I. Inclusiveness, collective learning and staff engagement A Learning Review should be multi-agency; bringing practitioners together with the review team in a structured process in order to reflect, increase understanding and identify key learning.

II. Support for staff Support for staff is critical and should be integral to the review process in order that they can participate fully in the process, reflect on their practice, share their knowledge and contribute to the emerging learning.

III. A systems approach The Learning Review does not stop at the points when shortcomings in professional practice have been recognised, it moves on to explore the interaction of the individual with the wider context, including cultural and organisational barriers, in order to understand why things developed in the way they did. The focus is on:

• what happened
• how some assessments were made
• understanding how people saw things at the time; what knowledge was drawn on to make sense of the situation; the resources available and the emotional impact of the work
• effective practice
• identification of learning points and how these will be actioned and implemented in future practice and systems

IV. Proportionality and flexibility The situations under review will inevitably be complex and diverse and this therefore requires a streamlined, proportionate and flexible approach to ensure effective learning. This flexible approach remains grounded in the underpinning principles and values of Learning Reviews.

V. Timing and Timelines Long review processes should be avoided. Optimum learning arises not just when the process allows significant events to be identified but also when it is relevant for the current practice context.

Underpinning principles and values

Learning Reviews are underpinned by the following core principles and values:

• they promote a culture that supports learning
• their emphasis is on learning and organisational accountability and not on culpability
• they recognise that a positive shared learning culture is an essential requirement for achieving effective multi-agency practice
• they are objective and transparent
• they are sensitive to the needs and circumstances of children, young people and families
• they ensure that staff are engaged and involved in the process and supported throughout the period of the review
• they recognise the complexities and difficulties in the work to protect children and young people and to support families
• they produce learning which can be disseminated, both at local and national level, so it directly impacts on and positively influences professional practice and organisational systems

Creating the preconditions for learning

Learning Reviews are not investigations. They are an opportunity for in-depth analysis and critical reflection in order to gain greater understanding of inevitably complex situations and to develop strategies to support practice and improve systems across agencies. It is important, therefore, to create and sustain a positive shared learning culture throughout the process of the Review.

Reviewing complex situations can raise anxiety in individuals and organisations. This anxiety can block learning by generating defensiveness, with a consequent inability to review and reflect. In order to create the preconditions for learning it is essential that individuals who are part of the review process feel safe^[1] so that they can begin to honestly consider what has happened and engage in appropriate and constructive questioning and challenge. This will then result in the development of ideas and realistic and realisable action plans. Clarifying objectives, setting out purpose and being transparent about expectations, based on a culture of respect and value for all professions and services, will help to minimise defensiveness and manage the inevitable anxiety within organisations, systems and individuals.

Effective leadership is crucial to creating the preconditions for learning. Chief Officers, who are accountable for all of the work of the Child Protection Committee, must promote and support national learning and improvement activity in the protection of children as a matter of course, providing leadership and guidance in relation to the need to carry out Learning Reviews.

Criteria for undertaking a Learning Review

A Child Protection Committee will undertake a Learning Review in the following circumstances:

When a child has sustained significant harm or risk of significant harm as defined in the National Guidance for Child Protection in Scotland

And there is additional learning to be gained from a Review being held that may inform improvements in the protection of children and young people

and one or more of the following apply:

• abuse or neglect is known or suspected to be a factor in the child’s sustaining of or risk of significant harm
• the child is on, or has been on, the Child Protection Register (CPR) or a sibling is or was on the CPR or was a care experienced child (i.e. looked after, or receiving aftercare or continuing care from the local authority). This is regardless of whether or not abuse or neglect is known or suspected to be a factor in the child sustaining of significant harm, unless it is absolutely clear to the Child Protection Committee that the child having been on the CPR
• or being care experienced has no bearing on the case
• the child’s sustaining of or risk of significant harm is caused by attempted suicide, alleged attempted murder, reckless conduct, or act of violence
• the child is being managed under Care and Risk Management (CARM) processes and causes harm to another person or themselves.

When a child has died

and (bold) there is additional learning to be gained from a Review being held that may inform improvements in the protection of children and young people

and one or more of the following apply:

• abuse or neglect is known or suspected to be a factor in the child’s death or the sustaining of or risk of significant harm
• the child is on, or has been on, the Child Protection Register (CPR) or a sibling is or was on the CPR or was a care experienced child (i.e. looked after, or receiving aftercare or continuing care from the local authority). This is regardless of whether or not abuse or neglect is known or suspected to be a factor in the child’s death, unless it is absolutely clear to the Child Protection Committee that the child having been on the CPR or being care experienced has no bearing on the case
• the child is being managed under Care and Risk Management Processes
• the child’s death is by suicide, alleged murder, suspected culpable homicide, reckless conduct, or act of violence

Please be reminded that, following the establishment of the National Hub for Reviewing and Learning from the deaths of Children and Young People, all child deaths should be reviewed (see page 8). A range of review processes are currently in place when a child or young person dies. Therefore early discussion between child/public protection leads, NHS Board and local authority implementation leads for child death reviews, and relevant senior officers from the local authority/Health and Social Care Partnership (HSCP), will be important to consider and agree the most appropriate review process.

Learning Reviews may also be undertaken where effective working has taken place and outstanding positive learning can be gained to improve practice in promoting the protection of children and young people.

This criteria does not preclude a CPC reviewing the death of a child pre-birth.

Parallel or other processes

Learning Reviews are one of the many processes that exist to support continuous improvement. Where a child or young person is significantly harmed or has died and the criteria for a Learning Review have been met there may be parallel processes to consider due to the specific circumstances for that child or young person.

The parallel processes to be considered may include (this is not an exhaustive list):

• local authority report on the death of a looked after child
• NHS significant critical incident or significant adverse event reviews
• Drug-Related Death Review
• Fatal Accident Inquiries (FAI)
• police investigations
• report of death to the Procurator Fiscal
• ongoing criminal proceedings
• independent investigations by the Police Investigations and Review Commissioner
• death-in-prison learning audit and review held jointly within two weeks of a death in custody by the Scottish Prison Service and NHS
• Multi-Agency Public Protection Arrangements (MAPPA)
• Mental Welfare Commission Review
• Scottish Children’s Reporter Administration (SCRA) - ongoing proceedings (possibly involving a children’s hearing or court) following referral to the children’s reporter
• local authority Serious Incident Reviews
• disruption meetings and Carer Review Panels that public and provider agencies hold internally when there is a significant detrimental event in a child’s placement (including abusive)
• Sudden Unexplained Deaths in Infants (SUDI)
• Suicide Reviews

These processes have distinct purposes, and some are the subject of separate statutory guidance. No process is inherently more important and therefore expected to automatically take precedence, however where there are ongoing criminal proceedings or an FAI, or ongoing proceedings following referral to the children’s reporter, the Crown Office and Procurator Fiscal Service (COPFS) may include conditions that impact on whether a Learning Review can be easily progressed or concluded. To help establish what status a Learning Review should have relative to other formal investigations there should be ongoing dialogue with Police Scotland, COPFS, Scottish Children’s Reporter Administration (SCRA) or others to determine how far and fast the Learning Review process can proceed in certain cases. Good local liaison arrangements are important. Issues to be considered include how to:

• link processes
• avoid witness contamination
• avoid duplicate information being collected
• decide whether to postpone a Learning Review if a parallel process is running, and wait for the determination of the parallel proceedings

Where a case is subject to police investigations, court proceedings, or proceedings following referral to the children’s reporter, these should not inhibit the setting up of a Learning Review nor delay immediate remedial action being taken to improve services. It is important that the purpose of the review process, which is to support professional and organisational learning and to promote improvement in future inter-agency child protection practice, is understood and remains the focus. The COPFS and Police Scotland have a protocol which recognises that criminal proceedings can be managed simultaneously (see Annex 2). This is a National Protocol agreed by COPFS, Police Scotland and Child Protection Committees to provide a framework for the sharing of appropriate information generated through both processes wherever possible.

In all other cases, consideration must be given to the potential parallel processes listed above, with a multi-disciplinary meeting taking place to agree how best to proceed at the earliest opportunity, in order to minimise duplication and maximise learning. The Child Protection Committee will discuss the most appropriate review type and sequence with the body responsible for the parallel process.

These processes contribute to increasing confidence in public services, providing accountability and a level of assurance about how those services acted in relation to a situation concerning a child.

Confidence in the agreed process and a joint commitment to keeping the child and their family at the centre will ensure that a robust and shared learning culture takes place without delay.

National Hub for Reviewing and Learning from the Deaths of Children and Young People

The National Hub for Reviewing and Learning from the Deaths of Children and Young People has been set up by the Scottish Government to ensure that the death of every child in Scotland is subject to a quality review and that there is a consistent approach and coordinated process for all local review activity that is undertaken in relation to learning from the circumstances surrounding the deaths of all children and young people in Scotland. The overarching purpose of the National Hub is to ensure that data generated from these reviews will inform national policy, education and learning and contribute to the prevention of child deaths in the future.

The National Hub, hosted by Healthcare Improvement Scotland and the Care Inspectorate, will ensure reviews are conducted on the deaths of all live born children up to the date of their 18th birthday, or 26th birthday for care leavers who are in receipt of aftercare or continuing care at the time of their death.

When a health board or local authority is notified about the death of a child or young person there should be clear governance arrangements and processes in place to determine the appropriate review mechanism. Engagement must take place early in the process with any other organisations involved in the child or young person’s care to reach a decision about the most suitable review process. All organisations and agencies involved should work together to undertake one single review wherever this is possible and appropriate. The rationale for deciding which review process should be carried out should be clear, take into consideration any statutory, legal, or national requirements, and be reached in a timely manner. A National Child Death Review and Learning Hub process map can be found at Annex 3.

The National Hub for Reviewing and Learning from the Deaths of Children and Young People guidance sets out the implementation processes for health boards and local authority areas when responding to, and reviewing, the death of a child or young person. Whilst organisations can establish their own structure and process for reviewing the deaths of children and young people, they should ensure the local processes align to this. National Hub Guidance, titled ‘National Guidance when a Child or Young Person Dies’ can be found Healthcare Improvement Scotland's website.

National Hub Core Review Data Set

If the child or young person who was the subject of the Learning Review has died, then the National Hub requires the completion of the Core Review Data Set at the conclusion of the Learning Review Process. The Core Review Data Set is included in the National Hub for Reviewing and Learning from Deaths of Children and Young People – National Guidance for when a Child or Young Person Dies.

This dataset information will enable the consistent gathering and analysis of data on all child deaths across Scotland. Only one dataset should be completed per child/young person. The local area child death review group should agree who will be best placed to do this. Core review dataset information should be completed online and uploaded to the National Hub via the secure electronic portal. NHS Board and local authority implementation leads for child death reviews have been provided with information on how to access to the portal. For more information, contact the National Hub team at his.cdrnationalhub@nhs.scot.

More information about the core review dataset can be found Healthcare Improvement Scotland's website.