Multi-Agency Public Protection Arrangements (MAPPA): national guidance

20. MAPPA Significant Case Review Process

Introduction

20.1 It is recognised that, on occasion, individuals managed under MAPPA may cause or be subject to serious harm. When either of these occur the MAPPA policies and processes should be examined and where it has been identified that these could be improved, plans are put in place promptly to do so. The Significant Case Review (SCR) process provides a consistent framework to enable MAPPA Strategic Oversight Groups (SOGs) to examine the quality of practice and adherence to legislation and guidance. The reviews should focus on learning and reflection around day-to-day practices and processes, and the systems within which they operate. They should identify strengths as well as areas for development and are intended to contribute to a culture of continuous learning to improve future practice.

20.2 This chapter sets out the 4 stage escalation process which may conclude in an SCR if the examination of the background to an incident is progressed to the final stage.

Identification of a Significant Case

20.3 For the purpose of this process, a significant case should meet one or more of the following 3 broad criteria:

• Where someone currently being managed under MAPPA has been charged with a further offence(s) which has resulted in the death or serious harm of another person.
• Where significant concern has been raised about professional and/or service involvement, or lack of involvement, in respect of an individual being managed under MAPPA.
• Where an individual being managed under MAPPA has been subject to serious harm or died as a direct result of their MAPPA status.
• Where an individual being managed under MAPPA has died or been subject to serious harm in circumstances likely to generate significant public concern.

20.4 When an incident which meets one or more of the above criteria occurs, the relevant SOG should examine the practices and processes employed by the Responsible Authorities and the Duty to Co-operate (DTC) agencies. Where improvements are identified, plans must be put in place promptly to implement these. All good practice and learning identified should be considered for sharing locally and nationally where appropriate.

20.5 The Responsible Authorities must have in place local mechanisms for identifying all cases which meet the criteria at 20.3 and must report every incident which falls within the criteria to their SOG Chair. Any agency (including those providing Third Sector services), profession, or individual can also report incidents which meet these criteria to the SOG Chair.

MAPPA SCR process

Objectives

20.6 The overarching objectives of the SCR process are:

• To identify learning and good practice in order to promote continuous improvement;
• Where appropriate, make recommendations for action (although any immediate actions required must not await the outcome of a formal review);
• To provide public reassurance on efficacy of MAPPA; and
• Ensure a proportionate approach is taken when deciding whether to progress to the next stage of the process. A case should not be escalated beyond what is proportionate, in the circumstances.

Other processes and linked investigations

20.7 There are a number of similar review processes in place across public protection which include (but are not limited to) Child Protection, Adult Protection, Health Clinical Incident Review (CIR), Serious Incident Review (SIR) carried out by the Care Inspectorate, criminal proceedings and the Scottish Children's Reporter Administration (SCRA) reports.

20.8 It is possible for more than one of these processes to be triggered as a result of the circumstances of an incident. In such cases agreement should be sought on the most appropriate way to proceed, taking account of the requirements of each process, the potential for cross-cutting, and the potential impact on the welfare of those involved, including staff and those providing evidence.

20.9 Other processes running concurrently with the SCR process raise a number of issues including:

• The relationship of the SCR with other processes, such as criminal proceedings, on-going criminal investigations or SCRA reports;
• Securing co-operation from all agencies in relation to the release and sharing of information;
• Minimising the potential for duplication; and
• Ensuring a sufficient degree of rigour, transparency and objectivity.

20.10 Where the individual concerned is subject to an Order of Lifelong Restriction, the Risk Management Authority will undertake an evaluation of the implementation of the Risk Management Plan (RMP) where there has been a death or serious harm caused.

20.11 There may be reasons why an SCR cannot be immediately initiated or concluded, such as where there is an on-going criminal investigation, or where there are links to a Fatal Accident Inquiry, or Children's Hearings Proceedings. Liaison with the appropriate body will establish how to proceed. In particular criminal investigations always have primacy.

20.12 To establish what status a case going through the SCR process should have in relation to a linked on-going criminal investigation, the SOG should seek advice from the Crown Office and Procurator Fiscal Service (COPFS) and/or Police Scotland.

Role of the SOG in the SCR process

20.13 The local SOG in the first instance has responsibility for the formal review of a significant case and for ensuring the processes set out in this guidance are followed, evidenced and recorded appropriately.

20.14 By following these processes, the SOG will be able to:

• Review the incident at a level which is necessary, reasonable and proportionate;
• Adopt a consistent, transparent and structured approach;
• Identify the skills, experience and knowledge required by those undertaking the SCR process, and the support they may find helpful during the four stages of the process;
• Address the needs of the individuals and agencies who may have a legitimate interest in the SCR;
• Take account of the evidence; and
• Ensure implementation of actions and learning are completed timeously.

Role of the Chief Officers Group (COG) in the SCR process

20.15 The governance for public protection sits with every COG for their respective area. It is expected that their level of involvement in the SCR process would be:

• Where the SOG has reviewed an Initial Notification Report (INR) or an Initial Case Review (ICR) and they wish to proceed to an SCR, the COG should be given the opportunity to consider the associated costs and funding of the SCR, including any contractual agreements;
• The COG should be sighted on the Terms of Reference (ToR)/remit for the SCR when drawn up at the start of the SCR process;
• Where the decision by the SOG following an INR or an ICR is not to proceed to further, the COG should be informed of the rationale for that decision; and

• Any disputes during the SCR process which cannot be resolved should be escalated to the COG for consideration.

The Key Stages

20.16 There are 4 key stages within the SCR process although Stage 2 may not be necessary depending on the circumstances:

• Stage 1: Initial Notification Report (INR)
• Stage 2: Initial Case Review (ICR)
• Stage 3: Decision on whether or not to proceed to an SCR
• Stage 4: The SCR process

20.17 At any point, the SOG can decide not to progress further, on the basis of the evidence provided. In these circumstances, the decision and the rationale for the decision should be clearly documented and recorded on the Violent and Sex Offender Register (ViSOR). To enable easy identification and to be readily searchable within that case, the ViSOR activity log entry should be clearly dated and headed.

Stage 1: Initial Notification

Initial Notification Criteria

20.18 The SCR process begins with an Initial Notification Report (INR) which is triggered by one or more of the incidents listed at 20.3.

20.19 Where the further offending has not resulted in serious harm or death, in order to promote learning the SOG should have mechanisms in place outwith the formal ICR/SCR process to carry out a review which is proportionate in the circumstances. This should include whether the defensibility test of "Was everything done which could reasonably have been done?" was met. It is recommended that the MAPPA Co-ordinator is advised of all offending irrespective of the level of seriousness.

20.20 Once a case has been identified as meeting one or more of the criteria at 20.3 (which may be through very early multi-agency discussion), the lead Responsible Authority will submit an INR to the SOG Chair and the MAPPA Co-ordinator within five working days. Where the Chair of the SOG also has a senior role within the lead Responsible Authority, the INR should be submitted to the SOG Vice-Chair and copied to the MAPPA Co-ordinator. An INR form can found within the MAPPA document set of this guidance.

20.21 Where the lead Responsible Authority is unable to submit the INR within five working days, this must not preclude any actions being taken which are required to protect the public or the individual concerned. Where the five-day deadline is not met, the reasons for this should be provided to the SOG Chair in writing and a new date for submission agreed.

20.22 The sharing of personal data must only take place when it is justified, necessary and lawful to do so. When completing the INR, the lead Responsible Authority must ensure compliance with the Data Protection Act 2018. Further information on the legislative requirements including processing data for law enforcement purposes can be found on the Information Commissioner's Office (ICO) website.

20.23 As a minimum, the INR should include a brief summary of the points listed below:

• A clear and concise description of the circumstances and the basis for the INR being submitted;
• Key events timeline;
• A brief outline of agency/professional involvement role and responsibilities;
• What actions have been or will be taken on behalf of the victim(s);
• Any other on-going formal proceedings;
• Evidence of good practice (including how/if this has been disseminated as part of shared learning);
• Areas for improvement and how/if these have been addressed;
• Details of risk assessments;
• Latest MAPPA minutes (or relevant extracts thereof) and;
• Recommendations for any actions still outstanding including the rationale for progressing further (or not).

20.24 Within five working days of receipt of the INR, the SOG Chair will assess whether there is sufficient evidence to make a fully informed decision on whether or not to proceed to an SCR. A Review of Initial Notification by SOG Chair form can be found within the MAPPA document set of this guidance. The decision and the rationale for the decision should be recorded locally in the INR register.

20.25 Where it is considered that there is insufficient detail to enable this decision to be made, the SOG Chair will advise the lead Responsible Authority in writing within 2 working days that an ICR is to be undertaken and where necessary, specify what further information is required.

20.26 Where the individual is subject to statutory supervision and the criteria for a Serious Incident Review (SIR) under the Care Inspectorate SIR process is met, the SOG Chair should inform the local authority only if the outcome of their review of the INR is that it should not progress any further. (The local authority does not require to be informed where an ICR is to be undertaken). The local authority should submit a SIR notification to the Care Inspectorate within five working days of receipt of the SOG Chair's decision in accordance with the Serious Incident Review Guidance. This will ensure that the Care Inspectorate SIR process will commence in order to establish whether the circumstances meet the criteria for a SIR.

20.27 The completed INR and the SOG Chair's decision on whether or not to proceed further in the SCR process (recorded on the Review of Initial Notification by SOG Chair form) should be sent to all SOG members for their information.

Decision not to proceed further

20.28 The following may assist to inform the decision of the SOG Chair not to proceed further. Please note that this is not an exhaustive list:

• The information provided in the INR indicates that appropriate action has already been taken to identify and address all of the issues raised; and/or
• The information provided in the INR makes clear that the defensibility test was met and/or
• None of the criteria listed at 20.3 which would merit an SCR being triggered in the first instance were met. For example, there may have been further offending but it did not result in serious harm or death. In this instance, local arrangements which would sit outwith this formal SCR process should be followed (see 20.19 above).

Decision to proceed to Stage 2 – ICR

20.29 The following may assist to inform the decision of the SOG Chair to proceed to Stage 2 – ICR (this is not an exhaustive list):

• Further consideration of the circumstances of the case is required, which may include adherence to policies and procedures and whether improvements could be made. For example, could greater clarity be provided by way of additional guidance?
• Concerns have been raised about the quality of the risk assessment(s) undertaken or the risk management plan;
• It appears that MAPPA processes and procedures were not followed. For example, this may include:
  • Attendance and representation of agencies at key meetings was not consistent or at the appropriate level of seniority.
  • Information was not shared at the appropriate point which may have impacted on the quality of the risk management plan (such as prior to the individual accessing the community from custody).
• Concerns have been raised and evidenced (and not yet addressed) about professional and/or service involvement, or lack of involvement in the management of the individual. (For example, may the circumstances have benefitted from further consideration of advice received or involved specialist services such as mental health).

Decision to proceed directly to Stage 3

20.30 Where the SOG Chair considers that the information provided in the INR is sufficient to merit proceeding directly to Stage 3 without an ICR, they should bypass Stage 2.

Recording an INR

20.31 Where it has been determined by the SOG Chair that the circumstances of the case do not merit proceeding further, the decision and the rationale for the decision must be clearly documented and recorded locally in an INR register.

20.32 This information should also be recorded on ViSOR. To enable easy identification and in order to be readily searchable within that case, the ViSOR activity log entry should be clearly dated and headed.

20.33 Any relevant learning identified should be shared with all Responsible Authorities and DTC agencies as appropriate. It is expected that key learning points would be anonymised and shared on the Scotland MAPPA Community Hub by the MAPPA Co-ordinator.

Stage 2: Initial Case Review (ICR)

20.34 Where the SOG Chair considers that an ICR is required, they will request that the lead Responsible Authority submits an ICR report within eleven working days.

20.35 If there are extenuating circumstances and the timescale for undertaking the ICR is not possible, the lead Responsible Authority must inform the SOG Chair at the earliest opportunity (in writing) and a new date for submission agreed.

Conducting an ICR

20.36 The sharing of personal data must only take place when it is justified, necessary and lawful to do so. As with an INR, the Responsible Authority must ensure compliance with the Data Protection Act 2018 when completing an ICR report. Further information on the legislative requirements including processing data for law enforcement purposes can be found on the Information Commissioner's Office (ICO) website.

20.37 As a minimum, the ICR report should include the information below:

• Level of MAPPA management and role of Responsible Authorities/DTC agencies in the day to day management of the individual;
• Details of the risk assessment(s) and risk management plan in place at the time of the incident. It is expected that for Level 2 and Level 3 cases, the risk management plan will be provided with the ICR;
• Detailed description of incident including details of relevant actions taken by Responsible Authorities immediately before, during and after the incident;
• Details of issues identified and actions already taken to address them. This can be added as an addendum to the ICR (for example as an action plan);
• Details of impact on the victim(s), the individual (where appropriate) and the wider community;
• Details of any other relevant review/criminal proceedings relating to the case, including status and timescales;
• Any responses to the incident by wider community or the media; and
• Recommendations for any actions still outstanding including the rationale for progressing (or not) to an SCR.

20.38 Where it is considered that there is insufficient detail to enable this decision to be made, a request for further information will be made by the SOG Chair within two working days to the lead Responsible Authority and where necessary, specify what information is required.

Recording an ICR

20.39 As with INRs, each SOG should maintain a register of all ICRs. The decision and the rationale for the decision on whether to proceed to Stage 3 should be clearly documented and recorded locally in the register and on ViSOR. To enable easy identification and in order to be readily searchable within that ViSOR case, the ViSOR activity log entry should be clearly dated and headed.

20.40 Any relevant learning identified should be shared with the Responsible Authorities and DTC agencies as appropriate. It is expected that key learning points would be anonymised and shared on the Scotland MAPPA Community Hub by the MAPPA Co-ordinator.

20.41 The SOG should produce a summary of all ICRs referred during the reporting year and, irrespective of the outcome, introduce these into the learning cycle to improve multi-agency learning and development.

Stage 3 SOG's decision on whether or not to proceed to Stage 4 Significant Case Review (SCR)

20.42 The decision to proceed (or not) to an SCR is a matter for the SOG. The SOG should review the INR or the ICR where one was undertaken, and make the decision within ten working days of receipt.

20.43 To assist with reaching a decision, the SOG may wish to consider whether to refer the case to relevant subject matter experts outwith the local authority area for their views. This is considered to be good practice.

20.44 A proportionate approach must be taken when deciding whether to progress to an SCR. A case must not be escalated beyond what is proportionate in the circumstances.

20.45 Where there is a split decision within the SOG on how to proceed, the Chair will make the final decision.

20.46 Where the SOG Chair also has a senior role within the lead Responsible Authority for the case being considered, it is expected that this decision would be passed to the Vice-Chair to make.

20.47 Any disputes on how to proceed which cannot be resolved should be escalated to the COG for consideration.

20.48 Where the decision is to proceed to an SCR, it is the responsibility of the SOG to inform the victim or nearest relative and to decide the appropriate timing for this depending upon the circumstances.

SOG's decision not to proceed to Stage 4 – SCR

20.49 The following may assist to inform the decision of the SOG not to proceed to an SCR (this is not an exhaustive list):

• On reading the INR or the ICR where one has been undertaken it is clear that single agency action is deemed appropriate;
• It would not be proportionate in terms in the circumstances to commission a full SCR although it may be considered that an action plan should be drawn up and overseen by the SOG to address outstanding issues;
• The information provided indicates that appropriate action has already been taken to address the issues raised in the INR or ICR; and
• The information provided shows that appropriate risk assessment(s) were undertaken, the risk management plan was fully implemented and the defensibility test was clearly met.

20.50 However, even in such circumstances, the SOG may decide that an SCR is appropriate.

No further review needed but follow-up action required.

20.51 Where the decision of the SOG is not to progress to an SCR, the SOG must ensure that an action plan is in place to address any local recommendations within the INR and/or ICR. Actions should be recorded with lead agency outcomes and timescales for completion included in the plan.

Decision to proceed to Stage 4 - SCR

20.52 The following may assist to inform the decision of the SOG to proceed to Stage 4 - SCR (this is not an exhaustive list):

• There are significant concerns about the quality and/or implementation of the risk management plan.
• The case has raised significant public concern about the efficacy of MAPPA.
• The commissioning of an SCR is proportionate in the circumstances, in order to identify learning and good practice in order to promote continuous improvement.

Notification of SOG's decision to proceed or not to an SCR

20.53 Within ten working days of the decision being made by the SOG to proceed or not to an SCR, they will notify in writing, clearly outlining the rationale for that decision:

• the Chief Officers Group;
• all the agencies involved in the case; and
• the Scottish Government Public Protection Unit.

20.54 Where the individual is subject to statutory supervision and the criteria for a Serious Incident Review under the Care Inspectorate SIR process is met, the Care Inspectorate should be informed of the SOG's decision to proceed or not to an SCR. Where the decision is not to proceed further, the local authority should submit an SIR notification to the Care Inspectorate within five working days of the SOG's decision in accordance with the Serious Incident Review Guidance. This will ensure that the Care Inspectorate SIR process will commence in order to establish whether the circumstances meet the criteria for a SIR.

Recording SOG's decision

20.55 The decision to proceed or not to an SCR and the rationale for the decision should be clearly documented and recorded locally in the SOG's ICR register and on ViSOR. To enable easy identification and be readily searchable within that ViSOR case, the ViSOR activity log entry should be clearly dated and headed. A copy of the SOG SCR Decision form can be found within the MAPPA document set of this guidance.

Stage 4: The SCR Process

Commissioning an SCR

20.56 Once the decision has been taken to proceed to an SCR (and taking account of the role of the Chief Officers Group in this process as detailed at 20.15), the process must be initiated as soon as possible. The SOG must decide whether to commission the SCR internally, or externally. In either circumstance, the following matters need to be agreed by the SOG from the outset:

• The type of support that can be provided to the Lead Reviewer and the Review Team, including whether establishing an independent reference group who have subject matter or expertise could assist;
• A secure method for exchanging information;
• That the SOG will work in partnership with the Lead Reviewer to develop the Terms of Reference (ToR) for the SCR; and

Where the report (partial or full) will be published and by whom. While it is for the SOG to make this decision, there should close collaboration with the COG on this. It is expected that consideration would be given to publishing it on the local authority website of where the incident took place in order to maintain transparency.

20.57 The SOG may find it helpful to form a sub-group to direct and manage the SCR process.

Internal SCR

20.58 Where the decision by the SOG is to commission an internal SCR, it will be delivered by one of the local Responsible Authorities within the SOG region.

20.59 In such cases, the Lead Reviewer and the Review Team should be drawn from the Responsible Authorities, excluding those departments/agencies who were directly involved in the management of the individual. The SCR should be led by someone who is independent and who is seen as being independent in order to maintain public confidence in the SCR process. It is expected that they would therefore not be a member of the lead Responsible Authority involved in the management of the individual. The SOG should ensure that the Review Team lead has the necessary level of seniority and experience in MAPPA.

20.60 The SOG may consider that an external specialist or consultant is required to undertake certain aspects of the SCR. Their costs should be met by the Responsible Authorities.

External SCR

20.61 Where the decision by the SOG is to commission an external SCR (by a Lead Reviewer from outside the SOG region), the ownership of the procedure remains with the SOG. This decision may include (but is not limited to) cases where:

• There are likely to be recommendations that have national significance;
• The case is high profile and likely to attract considerable media attention;
• MSPs, Elected Members, and others, have raised concerns about the case;
• The victim(s), or their nearest relative have raised concerns about the actions of the agencies involved in the case;
• Certain aspects of the case would benefit from specialist knowledge from an external source; and/or
• There would be a conflict of interest if the SCR were to be carried out internally.

Timescales

20.62 In every case, the SOG should agree a deadline for the submission of the final report, taking into account the circumstances and context of the case. When considering the deadline, if there are active criminal proceedings, it would be expected that the report would be finalised and submitted to the SOG no later than six months from the date of sentencing. Where that is not the case, a period of nine months from the date of the SOG commissioning the SCR should be considered the standard for the submission of the report.

20.63 These timescales must not preclude the taking forward of any immediate recommendations.

20.64 When deciding timescales, the following matters need to be considered by the SOG and realistically factored into the timeline from the point of commissioning:

• Any on-going criminal investigations and associated court proceedings;
• Procurement and recruitment of a Lead Reviewer;
• Practical arrangements including identifying secure workspace/accommodation; and
• Process for agreeing the ToR including an escalation process for agreeing changes/factual inaccuracies and revised drafts. All contributors to the review must be given the opportunity to carry out a factual accuracy check of interim and/or final reports.

20.65 Final agreement and acceptance of the SCR report by the SOG including its distribution and the publication of the Executive Summary and recommendations, should take place within six weeks of receipt unless there are extenuating circumstances.

20.66 The SOG will require the agencies to work expeditiously in preparing and submitting information within agreed timescales. Where the Lead Reviewer, Review Team or an agency consider that they are unlikely to meet an agreed deadline, this should be notified in writing to the SOG at the earliest opportunity along with an explanation and estimated date of completion. Consideration should also be given to informing the victim or their nearest relative of changes to the date of completion.

20.67 Preparation and planning are important to ensure the objectives of the SCR are met, and the following areas should be considered:

A. Developing the ToR;

B. Identifying and commissioning the Lead Reviewer and the Review Team;

C. Resources;

D. Managing the process;

E. Liaison with the victim and/or nearest relative/partner/family;

F. Staff;

G. Production, handling and publication of report (including communication strategy);

H. Follow Up; and

I. The learning cycle.

A. SCR – Developing the Terms of Reference (ToR)

20.68 A clear remit is essential to manage the expectations of those involved in the SCR as well as the wider audience for the finalised SCR report.

20.69 The ToR will be developed by the SOG and the Lead Reviewer should be given the opportunity to review it and suggest changes. The complexity of the SCR might not become evident until it has commenced. Consequently, the initial ToR may require to be revised during the course of the review. The SOG must agree any changes and ensure that they are evidenced and recorded appropriately and shared with the COG.

20.70 The ToR will outline the purpose of the review. The review should seek to:

• Establish a chronology to include all relevant incidents, meetings, discussions, decisions and contact with the individual and/or victim(s). The chronology must be endorsed by the relevant agencies as accurate. Consideration should be given to utilising a police analyst at this stage where the individual is a Registered Sex Offender.
• Establish the circumstances which culminated in the incident.
• Examine the role of the Responsible Authorities, DTC agencies and any other agencies involved in the management of the individual. Analyse the available information and identify any issues.
• If the victim(s) or other vulnerable individual(s) are interviewed as part of the review, the involvement of family liaison officers or specially trained interviewers must be considered.
• Identify areas of good practice in order to promote learning. Establish what lessons can be learned and how these can be shared to protect the public.
• Contribute to robust quality assurance procedures and demonstrate a commitment to continuous improvement.
• Develop and agree an action plan.
• Where consideration is being given to making a recommendation of national significance the Lead Reviewer or SOG should consult in advance with the relevant national body.
• Agree the format of the report which should be a clear read across to the ToR. There should also be a clear read across from the content of report to its recommendations.
• Establish the escalation process for agreeing changes/factual inaccuracies and revised drafts (this should be included in the ToR). All contributors to the review must be given the opportunity to carry out a factual accuracy check of interim and/or final reports.
• Report findings to the SOG and the Scottish Government Public Protection Unit.

B. Identifying and commissioning the Lead Reviewer and the Review Team

The Lead Reviewer

20.71 An SCR should be led by someone who is independent and who is seen as being independent in order to maintain public confidence in the SCR process. It is expected that they would therefore not be a member of the lead Responsible Authority involved in the management of the individual. They must be able to provide impartial scrutiny of the situation outwith the intrinsic and inherent knowledge that the Responsible Authorities and DTC agencies may have of local processes.

20.72 The Lead Reviewer must have an understanding of the roles of the Responsible Authorities and DTC agencies and how they work together within the MAPPA framework to manage risk. They should also understand the complexities of risk management. While they will be supported by the Review Team and subject matter experts from relevant agencies experienced in MAPPA procedures and practice, they may seek specialist input (whether for the duration of the SCR or as and when required) depending on the circumstances.

20.73 The Review Team needs to have confidence in the Lead Reviewer's ability to deliver results and so the Lead Reviewer needs to be at a sufficiently senior level in order to have credibility. The Lead Reviewer should have proven experience of leading a review process in order to identify learning opportunities and good practice. References must be provided. While they do not need to have experience of leading an SCR, they should have an understanding of their purpose and how they differ from other proceedings.

20.74 A proven ability to make defensible decisions^[23] is important. They should have strong interpersonal skills and experience in developing positive relationships, negotiation and interviewing.

20.75 An SCR is resource-intensive and the time required to identify and source a dedicated Lead Reviewer should not be underestimated. The Review Team is a multi-agency group which should collectively have elements of the traits required of the Lead Reviewer as well as a detailed knowledge and operational expertise of how MAPPA operates, particularly in the MAPPA discipline under review. They should have had no direct involvement in the management of the individual.

20.76 The Review Team provides support and advice to the Lead Reviewer throughout the SCR process. Like the Lead Reviewer, they should have an understanding of the purpose of SCRs and how they differ from other proceedings.

Attributes, skills, experience and knowledge required of a Lead Reviewer and the Review Team

20.77 In collaboration with partners, the Scottish Government published National Guidance For Child Protection Committees Undertaking Learning Reviews (2 Sept 2021) which includes guidance on the specific attributes, skills, experience and knowledge that may be required of those who are involved in a Child Protection Learning Review. Given the commonality of purpose between the SCR and Learning Review processes, please refer to Annex 5 of the child protection guidance which sets these out. For ease of reference, these are listed below but have been amended to reference the SCR process.

Attributes

20.78 This section sets out the personal qualities or attributes that may be required by those who are part of a Review Team. These are supported by:

• examples of descriptors for each set of attributes, illustrating what a person with those attributes may say or do.
• an indication of whether the attributes are of particular relevance to the Lead Reviewer or Review Team Members.

20.79 This has been set out to support local decision-making and professional judgement. The specific attributes required, as well as their descriptors, will be dependent upon the nature of the SCR.

Attributes: Honest, fair, objective and open minded

Examples of descriptors:

• Is non-judgemental of individuals' and organisations' involvement in the case, with the focus on understanding the learning that can be taken from the case as a whole;
• Supports contributors to be open, honest and non-protective in presenting and discussing their own organisation's involvement with the case;
• Avoids hindsight bias so that reflections on policies, procedures, actions and experiences are at the time of the incident, and do not reflect on what is now known.

Applicable to: Lead Reviewer and Team Member

Attributes: Empathetic and calm manner

Examples of descriptors:

• Is sensitive to and empathetic of contributors' emotions, noting that contributors can be confused, angry, emotionally fragile, worried and/or in need of support;
• Remains mindful that, in an SCR, some contributors might feel more 'under the spotlight' than others and, hence, supports their participation in a safe manner;
• Brings a calm manner, reassurance and open approach to communication, paying attention to the 'power of words';
• Identifies and makes contributors aware of wellbeing and counselling services that are available to them;
• Maintains the confidentiality of the evidence throughout.

Applicable to: Lead Reviewer and Team Member

Attributes: Respectful and collaborative

Examples of descriptors:

• Is open to learning and recognise that no single individual will know everything about the case. Establishing a full picture of the situation requires trusting, listening to and learning from the information and views of all contributors;
• Respects and values all contributors.

Applicable to: Lead Reviewer and Team Member

Attributes: Methodical and rigorous

Examples of descriptors:

• Is systematic in requesting, collating and checking information required to build full case picture.

Applicable to: Lead Reviewer and Team Member

Attributes: Attention to detail

Examples of descriptors:

• Cross-checks information across different sources for building the full case picture;
• Identifies gaps or limitations in the information available to the Review.

Applicable to: Lead Reviewer and Team Member

Attributes: Flexible

Examples of descriptors:

• Makes and/or supports adjustments throughout the SCR to ensure that the purpose of the Review and the underpinning principles and values are followed.

Applicable to: Lead Reviewer and Team Member

Skills/Abilities

20.80 This section sets out the skills and abilities that may be required by those who are part of an SCR Review Team. These are supported by:

• examples of descriptors for each set of skills/abilities, illustrating what a person with those skills/abilities may say or do
• an indication of whether the skills/abilities are of particular relevance to the Lead Reviewer or Review Team Members

20.81 This has been set out to support local decision-making and professional judgement. The specific skills and abilities required, as well as their descriptors, will be dependent upon the nature of the SCR.

Skills/abilities: Leadership skills

Examples of descriptors:

• Leads planning, delivery and completion of the SCR;
• Oversees the identification and engagement by the Review Team of the relevant partners and suitable contributors to the SCR (e.g. professionals who have the appropriate knowledge, skills and attributes, senior managers, participants who can contribute and/or benefit from being involved in the SCR);
• Oversees the distribution of roles and responsibilities by the Review Team of SCR partners and contributors;
• Works to the expectations of the Terms of Reference and the parameters set within this.

• Ensures that the SCR remains proportionate, inclusive and collective, with a systems approach and focused on learning; reiterates the underpinning principles and values at various times during the SCR process, assertively bringing them to the forefront, where needed.

Applicable to: Lead Reviewer

Skills/abilities: Planning and organisational skills

Examples of descriptors:

• Ensures that a clear and realistic timetable for the SCR process is set out and makes suitable adjustments, where needed (e.g. amending the Review timetable to allow additional information to be provided);
• Ensures timely requests made for key documentation relevant to the Review from organisations involved (e.g. practitioner case notes, organisational policies, procedures etc.) and follows up with organisations where information is not provided;
• Ensures timely circulation of key documentation in advance of Review meetings;
• Manages and prioritises different work demands so that sufficient time is allocated to the SCR.

Applicable to: Lead Reviewer and Team Member

Skills/abilities: Facilitation and interpersonal skills

Examples of descriptors:

• Helps contributors to enter the SCR process feeling informed and supported (e.g. provides adequate information, including about the supports available; remains open for further clarifications etc.);
• Helps the victim or nearest relative feel supported and maintains a relationship with them, while managing the boundaries and responsibilities of this task (particularly relevant for those liaising with them);
• Works well in a group setting.
• Discusses and debates with others in an objective, non-judgemental and transparent manner, demonstrating that they have no 'hidden agenda' (e.g. openly shares their own thoughts and understanding of the case, tests key ideas with the Review Team).

Applicable to: Lead Reviewer and Team Member

Skills/abilities: Facilitation and interpersonal skills

Examples of descriptors:

• Establishes effective relationships with participants, noting that they will come with differing levels of status, expertise, experience and education;
• Effectively facilitates group work and manages complex group dynamics (is able to assess, react and change).
• Facilitates practitioner and manager events so that:
  • Participants understand the purpose of the SCR and the need to ensure that it remains proportionate, inclusive and collective, with a systems approach and focused on learning;
  • Trust is established between participants;
  • All participants can voice their views in a safe manner;
  • Discussion, debate, probing and constructive challenge are encouraged;
  • Meetings remain focused on the core purpose of the Review;
• By establishing their independence from any operational management responsibilities or decision-making in relation to the case under review, asks challenging but constructive questions;
• Puts participants at ease and encourages them to openly and honestly express their views and reflect on their involvement in the case;
• Uses a range of participatory and creative approaches to obtain the views and experiences of the victim or nearest relative and parents/carers and practitioners in a safe manner.
• Effectively chairs and facilitates SCR meetings (is able to assess, react and change).

Applicable to: Lead Reviewer

Skills/abilities: Active and reflective listening skills

Examples of descriptors:

• Shows interest in and empathy with the views expressed by others. Is respectful of the views expressed by others;
• Seeks to understand the idea expressed by the other person, then relays the idea back, to confirm that it has been understood correctly;
• Remembers what others said and builds on their contributions.

Applicable to: Lead Reviewer and Team Member

Skills/abilities: Analytical skills

Examples of descriptors:

• Reviews and assesses all information available (events/consultations/meetings minutes, practitioner case notes, organisational policies, procedures etc.) to develop a full and multi-faceted understanding of the case;
• Identifies gaps or limitations in the information available to the SCR;
• Is able to undertake own research, where there is a knowledge gap; Review Team are not expected to know everything, but they are expected to know where to seek and how to review evidence;
• Verifies information presented through cross-checking of information against other sources, in order to understand the multiple lenses of the case (e.g. whether facts and explanations provided are aligning and complementing one another, addresses contradictory perspectives etc.);
• Interprets and analyses the workings and shortcomings of complex, multi-agency systems (e.g. taking into account policies and procedures, resources, staffing levels etc.);
• Elicits and analyses information from a learning and person-centred perspective, looking at the wider impacts for practice and service delivery (e.g. going beyond the identified challenges and understanding what had caused them, the systems' implications and needed improvements);
• Makes sound judgements based on the information collected and analysed during the SCR, through logical thinking and a culture of collaborative problem solving.

Applicable to: Lead Reviewer and Team Member

Skills/abilities: Communication skills (written and oral)

Examples of descriptors:

• Is able to communicate with multiple audiences (e.g. children, young people, families, practitioners, Strategic Oversight Group and Chief Officers Group, as appropriate) about the SCR purpose, process, timetable and outcomes, in a clear and accessible manner. This may require:
  • Adopting different communication methods with specific groupings;
  • Providing updates throughout the SCR process.
• Conveys complex issues in a concise, well-structured and accessible manner, using plain English, listen wherever possible, so that multiple audiences (the family, practitioners, senior managers, elected members and the public) can understand the findings and learnings. The clarity is required in both written and verbal communication. The objective should be to draft the report so that it can be published;
• Uses a neutral tone in the report, with a focus on learning, not blaming;
• Balances the importance of providing detailed (but confidential) insight to the case with the learning that can be taken from it;
• Focuses on communicating key points of learning from the case.

Applicable to: Lead Reviewer

• Recognises and responds to non-verbal signs from others (e.g. body language, tone of voice etc.);
• Adapts and changes their communication styles where appropriate (for example, from a sensitive and listening style to a more assertive and challenging style where appropriate – where trust is achieved and probing and constructive challenge can be used).

Applicable to: Lead Reviewer and Team Member

Experience and knowledge

20.82 This section sets out the professional and practice experience and knowledge that may be required by those who are part of a Review Team. These are supported by:

• examples of descriptors illustrating what a person who has that area of experience and knowledge may say or do
• an indication of whether the area of experience and knowledge is of particular relevance to the Lead Reviewer or the Review Team

20.83 This has been set out to support local decision-making and professional judgement. The specific experience and knowledge required, as well as their descriptors, will be dependent upon the nature of the SCR.

Experience and knowledge: Systems insight

Examples of descriptors:

• Understands and can interrogate the workings of the whole system around the individual, including relevant single-agency and multi-agency procedures;
• Understands how organisations and systems influence and impact on how individuals operate;
• Knows where, and from whom, to get specific information and expertise in order to build a comprehensive understanding of the system;
• Has a good understanding of the differences in the terminology used by various agencies.

Applicable to: Lead Reviewer and Team Member

Experience and knowledge: Review methodologies

Examples of descriptors:

• Is knowledgeable and understands methodologies and approaches for undertaking Reviews.

Applicable to: Lead Reviewer

Experience and knowledge: Adult learning and group facilitation

Examples of descriptors:

• Has experience of facilitating active engagement within a group setting;
• Understands group processes and dynamics and has experience of helping people to explore, reflect and learn;
• Understands how to build on what participants and contributors have experienced and learnt in the past.

Applicable to: Lead Reviewer

Experience and knowledge: MAPPA experience

Examples of descriptors:

• Has an understanding of MAPPA practice, processes and procedures in Scotland and specific legal processes and requirements;
• Has an understanding of MAPPA organisational arrangements – both multi-agency working arrangements and internal organisational structures;
• Has an understanding of the complexity of communication, collaboration and cooperation within MAPPA practice and policy.

Applicable to: Lead Reviewer

Experience and knowledge: Related services knowledge

Examples of descriptors:

• Understands the role, practice and impact of services connected to MAPPA, e.g. social work, health, education, child and adult services, addictions or domestic violence.

Applicable to: Lead Reviewer and Team Member

Experience and knowledge: Legal and policy systems knowledge

Examples of descriptors:

• Understands relevant legislation and policy within the Scottish context;
• Differentiates between SCR remit and task as opposed to criminal or negligence proceedings;
• Understands roles, responsibilities and governance of SCR processes as set out in national and local guidance;

Applicable to: Lead Reviewer and Team Member

Experience and knowledge: Report writing

Examples of descriptors:

• Has experience of writing comprehensive reports in a concise, well-structured and accessible manner, allowing the findings and learnings to be understood by multiple audiences.

Applicable to: Lead Reviewer

Commissioning the Review Team

20.84 Issues for the SOG to consider when commissioning a Review Team:

• Ensure that the ToR is clear and deliverable;
• Establish clear reporting lines of accountability;
• Identify milestones and time-scales (in line with those laid out in this chapter) and agree the various stages in the process;
• Provide appropriate administrative support;
• Agree the method for obtaining additional resources if it becomes clear that these are necessary;
• Confirm that if issues arise that require urgent action, the SOG (and agencies) will be so advised;
• Agree process for managing and reporting of serious issues;
• Require external reviewers to be registered with the Information Commissioner's Office (ICO); and
• Identify a named point of contact person within the Review Team.

C. Resources

20.85 Section 11 of the Management of Offenders etc. (Scotland) Act 2005 requires the Responsible Authorities to keep MAPPA under review for the purposes of monitoring the effectiveness of the arrangements and making changes to them that appear necessary or expedient. The SOG is responsible for providing local leadership, monitoring performance and quality assurance of MAPPA and this encompasses the need to carry out an SCR when required.

20.86 Resource issues, which may need to be addressed:

• Agree any formal contractual arrangements with the Lead Reviewer and Review Team as appropriate. The COG will consider which agency will enter into the contract with any external reviewer(s);
• For internal SCRs, the SOG should consider the potential of having a person external to the relevant SOG to supplement the Review Team (for example, where specialist knowledge or experience is required);
• Arrange for any accommodation/space requirements the Review Team may require;
• Provide for the secure storage of files/documents;
• Agree the methodology to be used to record (including reasons for drafting revisions), index and retain documents and evidence in an easily retrievable format;
• Establish a reporting structure, frequency and format; and
• Agree a communications plan.

D. Managing the Process

20.87 Issues to be considered by the SOG and the Review Team in the management of the process may include:

• Over what time period events will be reviewed. The history and background of the individual concerned and the victim(s) will help to decide this;
• For external SCRs, the contract will reinforce that the SCR is owned by the SOG and they retain the right to proof-read the final draft and correct factual errors or misunderstandings;
• The agreement of a media strategy;
• The agreement of the report format;
• The agreement of a communications strategy (including a dissemination and publication process);
• The identification of named contacts in each agency with whom the review team can liaise;
• Confidentiality protocols for the Review Team;
• Whether there are likely to be issues of access to case records (for example, ViSOR) and how that will be addressed;
• The involvement, if appropriate, of the victim(s) or the nearest relative, how this will be managed and how they will be guided through the SCR process;
• Responsibility for liaison with the victim(s) or the nearest relative and how that will be managed;
• Responsibility for liaison with relevant staff members and the process for doing so;
• Briefing that will be provided for contributors and by whom. Briefing will normally be an oral discussion about the purpose of the review. The SOG will need to consider whether contributors should receive information about the areas to be covered in advance of the interview and whether the files should be available to them for reference;
• The arrangements that require to be in place for feedback to the contributors and the mechanisms that will be used to enable all contributors to check the factual accuracy of any interim and/or final reports; and
• Record retention policy.

E. Liaison with the victim(s) or nearest relative

20.88 It is important that the review is carried out in good time - not least to reduce stress on the victim(s), or the nearest relative and families. Further information regarding impact on victims can be found at Chapter 14.

20.89 It is important that the victim(s) or the nearest relative are part of the SCR process. Where an SCR has been commissioned legal criminal proceedings are likely to be active and therefore victim support will be available from the Victim Information and Advice service (the accredited victims support mechanism for witnesses in criminal trials). Dependent upon whether COPFS give permission or not, the Review Team may not be able to engage with the victim until after they have given their evidence or at the completion of the criminal trial.

20.90 At this point, the Review Team should consider what additional support should be offered to the victim as a result of being informed that an SCR is underway and specifically how they are engaged with in the SCR process. The specific type of support should be considered on a case by case basis but the SOG must ensure that the victim is offered support through the process.

20.91 The victim(s) or the nearest relative must be kept informed of the various stages of the review and the outcomes of these where they have indicated they wish to be involved. (This needs to be factored into the communication strategy).

20.92 It is expected that a member of staff (not the Lead Reviewer) would be assigned to be the single named liaison point throughout the review. The person carrying out this liaison role should first make contact with any existing victim advocates/services who are already providing support to the victim and be fully aware of the sensitivities and background of the case. Where no such services are involved, it is recommended that contact is made with an appropriate victim support agency for advice on how to support the victim.

20.93 The liaison role may include advising of the intention to carry out an SCR and making arrangements to interview the victim(s) or the nearest relative. Particular care must be taken with where and when the interview takes place and a trauma informed approach must always be taken. Members of the Review Team should be experienced and skilled in working with victims.

20.94 The victim(s) or the nearest relative, where they have indicated they wish to do so, should receive a copy of the Executive Summary and recommendations from the SOG in advance of publication. Consideration should be given as to whether they should receive an oral briefing in advance of publication. This should be factored into the communication strategy and considered in terms of the distribution of the report. It should be noted that any detail provided to the victim(s) or the nearest relative should be deemed to be in the public domain.

20.95 There may be occasions where a relative is subject to investigation or significantly involved in the case and in these circumstances the information provided to them may require to be limited. Liaison between Police Scotland and COPFS is required in such circumstances.

20.96 Families may seek to take legal action against an agency or agencies. Individual agencies' complaints procedures should be made available at the outset of the review, and throughout the SCR process, as deemed necessary and appropriate.

F. Staff

20.97 During the review, staff involved directly or indirectly in the process should feel informed and supported by their managers. This should be factored into the communication strategy. There may be parallel processes which staff are involved in as a consequence of the case (e.g. disciplinary proceedings) and these should be considered.

20.98 Each agency will have procedures for supporting staff. Line managers should always consider:

• The health and wellbeing of staff involved;
• Provision of welfare or counselling support;
• Training needs;
• Communications with staff and keeping people informed of the process in an open and transparent manner;
• An agreed procedure to be adopted if the SCR uncovers evidence of criminal acts or civil negligence related, or unrelated to the case under review;
• The need for legal/professional guidance and support; and
• The need to allow staff time to prepare for interviews and have the opportunity to bring someone with them for support, assuming that this person has not been involved in the case.

20.99 For staff involved in the SCR, a copy of the MAPPA National Guidance should be made available to them, together with a copy of the local operational protocols in place in their SOG area. Once the SCR has been completed the staff involved should be given a debrief on the review and the findings before the report is published.

G. Production, Handling and Publication of the Report

20.100 The SCR report should be delivered to the commissioning SOG who will thereafter deliver the report to the COG, the Scottish Government Public Protection Unit and any national agencies identified in any recommendations for improvement. Where there are active criminal proceedings, it is expected that the submission of the SCR report to the SOG will be within 6 months of sentencing. Where there are no active criminal proceedings, submission is expected to be within 9 months of the decision to commission the SCR.

20.101 It is important that there is a degree of consistency to the structure and content of reports, ideally the format and structure of the report should be agreed at the outset. This makes it easier to identify and use the learning and for read-across to other reports to be made. The report should include:

• An introduction: a summary of the circumstances that led to the review, stating the ToR and a list of contributors to the review (suitably anonymised);
• A separate Executive Summary and list of recommendations. This summary should be appropriate for publication, including being suitably anonymised;
• A clear chronology of key events;
• The nature and extent of the involvement of the victim(s) or nearest relative in the process;
• Findings based on the analysis of the circumstances culminating in the incident;
• Conclusions – extending from the findings; and
• Recommendations which must evidence-based and clearly linked to the findings. They need to be specific, focussed and achievable. The report should identify which body or agency each recommendation is for and any potential resource implications of its implementation. Where a proposed recommendation has national significance, liaison with the relevant body in advance is required.

20.102 The SOG will decide who will receive the report. The findings of an SCR will provide valuable information for the management of individuals subject to MAPPA at a local and national level. It is therefore expected that the Executive Summary and recommendations will be made public.

20.103 The Executive Summary should be sufficiently detailed to provide a reasonable overview and analysis of the case.

20.104 The Lead Reviewer, the Review Team and the SOG must ensure compliance with the Data Protection Act 2018 when conducting and reporting of the SCR. Further information on the legislative requirements including processing data for law enforcement purposes can be found on the Information Commissioner's Office (ICO) website.

Distribution List

20.105 The SOG should propose a distribution list for the full report to the COG. This should have regard to the guidance for a communication strategy and media handling set out at 20.110 to 20.115. It should consider any internal/external communications or briefing required before publication and confirm how best to co-ordinate media handling.

20.106 It is acknowledged that each significant case is unique and the SOG will endeavour to identify all who need to be informed, and who will be required to provide information at each stage of the SCR process. The Scottish Government Public Protection Unit should receive a copy of the report at least five working days prior to publication.

20.107 The distribution list should be proportionate to the individual case, but may include those with responsibility for local service delivery and review as follows:

• The SOG;
• Chief Officers: Chief Executive of Local Authority, Chief Executive of Health Board, Chief Constable, and Chief Executive of Scottish Prison Service;
• Director of Social Work, Chief Social Work Officer, Senior Managers in Police Scotland, Education and Health Service, and the relevant Prison Governor;
• Staff involved in the review;
• Crown Office and Procurator Fiscal Service;
• National Sex Offender Policing Unit;
• Parole Board for Scotland;
• The Mental Welfare Commission;
• Children's Reporter/Scottish Children's Reporter Administration;
• Inspectorates/Scrutiny Bodies such as The Care Inspectorate, HM Inspectorate of Constabulary Scotland, HM Inspectorate of Scottish Prison Service, HM Inspectorate of Education Services for Children Unit, Health Improvement Scotland, Mental Health Tribunal for Scotland and the Risk Management Authority;
• Victim(s) or the nearest relative;
• Local councillors and Health Board Chairs;
• Voluntary organisations and independent providers, where they are involved in the case; and
• The Scottish Government MAPPA National Strategic Group (NSG).

20.108 Those with wider interests in the SCR report may include:

• Local authority, health board and police media officers;
• Professional representative bodies;
• Legal representatives; and
• Unions and staff associations.

20.109 Other key interests are likely to be:

• The general public;
• Elected members (for example, MSPs, MPs); and
• The media.

Communication Strategy and Media Handling

20.110 Please note that this section provides general guidance only. Responsible Authorities and DTC agencies should prepare their own media and seek their own legal advice where necessary.

20.111 The SCR report is a document intended for shared learning and therefore requires a communications strategy. It is the responsibility of the SOG to report the outcome of the SCR to their COG and the Scottish Government Public Protection Unit. However, the SOG has extensive responsibilities and should consider the wider dissemination of the learning from the process and outcomes.

20.112 The SOG should make clear at the outset of the SCR where and by whom the Executive Summary and the recommendations should be published. While it is for the SOG to make this decision, there should be close collaboration with the COG on this. It is expected that publication would be within 6 weeks of completion of the SCR and that consideration would be given to publishing it on the local authority website of where the incident took place in order to maintain openness and transparency.

20.113 Information within any SCR will be highly sensitive and may be distressing. Each SOG should have agreed protocols in place with local agencies and the Scottish Government which includes named contacts and their role and responsibilities in the process (such as whether communication is for information or decision-making purposes).

20.114 All Responsible Authorities and DTC agencies should comply with their own organisations' and/or the SOG's agreed media strategy. It is important to note that there are strict guidelines in place for dealing with matters which are sub judice.

20.115 In responding to media enquiries, the SOG must have regard to wider interests over which they have no direct control. The importance of reassuring the public through any media statements and reducing alarm or confusion is paramount.

H. Follow-up to publication of the Report

20.116 Following publication of the SCR report, the SOG will be required to:

• Establish a process for managing the delivery of the findings and recommendations of the report;
• Prepare action and implementation plans and establish a means of monitoring progress;
• Seek regular updates on the progress of actions for national agencies;
• Establish audit processes to ensure all findings and recommendations have been considered and implementation processes agreed; and
• Liaise with the Scottish Government and others as required.

I. The Learning Cycle

20.117 The primary aim of an SCR is to identify learning opportunities and good practice in order to promote continuous improvement. These may relate to:

• Management;
• Policy;
• Protocols;
• Practice;
• Operating conditions; and
• Communication and partnership working.

20.118 The SOG will wish to consider how to promote learning and commitment to change including:

• Considering whether to identify one senior person to champion change.
• Communications to interested parties;
• Supporting and acknowledging good practice within and between organisations/service areas;
• Providing the MAPPA National Strategic Group (NSG) with a summary of the lessons learned and areas of practice which may require further discussion including whether any aspects would benefit from adopting a national approach; and
• Determining the impact on individuals or organisations (risk factors) as a result of change.

20.119 In addition, the SOG should consider how to:

• Increase public confidence in MAPPA in their region;
• Identify, plan and implement any required training; and
• Produce and implement long and short-term action plans.

20.120 The SOG will need to consider how to maintain change by:

• Putting quality assurance systems in place including monitoring and evaluation linked to reporting and action planning cycles;
• Engaging with stakeholders; and
• Supporting staff.

20.121 After the SCR has been published it may be necessary for SOGs in other areas to review their own guidance and procedures in light of the findings and recommendations from the review. This could be facilitated through the meetings of the NSG, or by specially convened local meetings depending on the urgency.

20.122 It is likely that some recommendations from ICR and SCR reports may require to be led and/or implemented nationally. Their findings will also be important for external scrutiny bodies in future inspections of services.

Significant Case Review Process

• Initial Notification Report (INR) sent to Strategic Oversight Group (SOG) Chair within 5 working days of identification.
• Within 5 working days the Chair considers if further detail is necessary for SOG to decide on progression or not to an SCR.
• If no further action and individual is subject to statutory supervision and the Serious Incident Review (SIR) criteria is met, Chair to inform local authority of decision.
• If insufficient detail for SOG to take decision, within 2 working days further information is instructed via Initial Case Review (ICR).
• The ICR is to submitted to the SOG Chair within 11 working days.
• Decision is taken by SOG to proceed or not to an SCR within 10 working days of receipt of INR or ICR.
• Irrespective of decision on whether to proceed or not to SCR, if the individual is subject to statutory supervision and the SIR criteria is met, local authority to inform Care Inspectorate of decision within 5 working days.
• If decision is to proceed to SCR, the victim or nearest relative is to be informed of the decision.
• If decision is to proceed to SCR, the Scottish Government, Chief Officers Group (COG) and the Responsible Authorities are to be informed within 10 working days.
• A lead reviewer and review team is appointed.
• Where active criminal proceedings, SCR expected to be with commissioning SOG within 6 months of sentencing. Where no active criminal proceedings, submission expected within 9 months of SOG's decision to commission an SCR.
• Publication expected within 6 weeks.