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6. THE SIGNIFICANT CASE REVIEW ( SCR) PROCESS

57. Research and experience indicate there are key areas where good preparation and planning are important to ensure the objectives of the SCR are met:

A. Developing the Remit

B. Identifying the Review Team

C. Commissioning the Review Team

D. Resources

E. Managing the Process

F. Producing, Handling and Delivering the Report

G. Follow-up

H. Family/Carers

I. Staff

58. Each of these is looked at in more detail in the following sections.

A - Developing the Remit

59. The outcomes of the review should be to:

• Identify whether inter-agency working can be improved to better protect children; and
• Contribute to the development and sustainability of robust quality assurance procedures and continuous improvement.

60. The clearer the remit the easier it will be to manage the expectations of those involved in contributing to the SCR and the wider audience for the outcome of the review. It is recognised that the degree of complexity and/or which people to involve might not become clear until some initial work has been undertaken - especially in the case of an external SCR. Consequently, the remit to commence the process may need to be reviewed as the information develops during the process. If changes are made to the remit over time, this should be agreed and appropriately documented.

61. The remit will relate to the purpose of a review as described in Section 1. The review should seek to:

• Establish a chronology of agencies' and professionals' contact with the child. Once the chronology has been established, it should be circulated to the agencies and professionals to check for accuracy;
• Establish the circumstances leading to and surrounding the death/serious harm of the child. It is recognised that this may be difficult if there are parallel inquiries taking place, e.g. a criminal investigation;
• Examine the role of all the agencies involved in providing care, welfare and protection services, and analyse and assess the circumstances drawing out the implications and issues. If the child or other children are being interviewed as part of this examination, consideration should be given as to whether special measures should be deployed for this element of the work;
• Establish whether there are lessons to be learned from the case, or good practice to be shared, about the way in which agencies work individually and collectively to safeguard children;
• Identify lessons, how they are to be acted on and what is expected to change as a result. This should consider whether there are gaps in the system and whether services should be reviewed or developed to address those gaps; and
• Make recommendations for local action (which could be single agency or multi-agency) and perhaps also for national action, spelling out resources that may be required to implement them (see Sections 6 and 7).

B - Identifying the Review Team

62. In the case of either an internal or external SCR, identifying the right reviewer and review team will be crucial. SCRs are resource-intensive and require a dedicated lead with the appropriate specialised support from the principal agencies to provide the necessary understanding of procedures and practice. In some cases it may also be necessary to have specialist input, whether as part of the team for the duration of the SCR or to provide advice as required; the Review team may wish to consult other CPCs and agencies.

63. It is important that the reviewer or someone in the review team has a broad knowledge of children's services as well as the necessary skills to lead/undertake the review. The interviewing of significant witnesses takes time and must be undertaken with perseverance and with sensitivity.

64. The best person to lead a review may be a recognised professional or external consultant who can bring a team together. It is important to assemble a mixed team so that the key agencies feel confident that their specialist issues are understood. The different perspectives of a mixed review team can add to the depth of enquiry.

65. Within a CPC, there may already exist a standing group that considers all potential significant cases (before it is determined whether or not they require a SCR). This standing group might then comprise the main reviewing team for an internal SCR, led by a member of the CPC or by the person with the best knowledge of the main areas that likely to be pertinent to that particular significant case. Nobody should investigate a situation in which they themselves were substantially directly involved professionally.

66. The lead reviewer and the review team will, between then, need to have the skills and competencies to undertake an SCR. These will differ according to the circumstances of each case but the reviewer/review team will need to be able to:

• Gather relevant evidence from a wide variety of sources and be prepared to negotiate if information is not forthcoming;
• Have skills of investigation;
• Test the validity of the evidence and sift the evidence;
• Interpret information from a wide variety of sources;
• Make sound judgements on information collected;
• Analyse the root cause of/factors that contributed to the significant case;
• Liaise with other bodies and establish a good working relationship;
• Demonstrate sensitivity to national and local level issues; and
• Appreciate the need for clarity about the difference of remit and task of an SCR as opposed to other ongoing proceedings relating to that case such as a criminal investigation.

C - Commissioning the Review Team

67. Here is a checklist of issues that are involved when commissioning a review team:

• Confirm that the remit clear and deliverable;
• Establish clear reporting lines and agree handling of the review itself and the report;
• Identify milestones and agree the various elements of the process;
• Consider whether indemnity cover is required;
• Provide for appropriate administrative support;
• Agree the method for obtaining additional resources if it becomes clear that these are necessary;
• Confirm that if issues arise that need urgent action, the CPC (and agencies) will be so advised;
• Require external reviewers to be registered with the Data Protection Office; and
• Establish a named contact person within the team.

D - Resources

68. The 2005 guidance for CPCs ⁷ states that Chief Officers have a collective responsibility to ensure that their CPC has the resources, including staff time and finance, to fulfil its roles and responsibilities (paras 2.6 and 2.7). Conducting an SCR falls within this area of responsibility. A checklist of resourcing issues to be addressed is provided here:

• Agree any formal contractual arrangements. The Chief Officers Group will consider which agency will enter into the contract;
• In the case of an internal SCR, CPCs should consider the potential of an external person to supplement the review team;
• Consider whether there are any training or information requirements;
• Agree how the review team's expenditure will be managed;
• Agree how the review team will be financed;
• Arrange for any accommodation/space requirements the review team require;
• Provide for secure storage arrangements for files/documents;
• Agree the methodology to be used to record, index and retain documents and evidence in an easily retrievable format;
• Agree the methodology to be used to record, index and retain documents and evidence in an easily retrievable format;
• Establish how often, to whom and in what format the review team should provide interim reports;
• Agree timescales with the principal stakeholders; and
• Agree a communications plan.

E - Managing the Process

69. Addressing the what, where and when issues of the SCR are vital to its successful operation. The issues to be discussed and agreed cover:

• The Review team should discuss the case with the Police and the Procurator Fiscal;
• What the remit of the review is (paras 59-61);
• Over what time period events will be reviewed. The family history/background information will help to decide this;
• To what extent will the review team has access to the commissioning CPC for on-going discussion;
• For externally commissioned SCRs, how the contract will allow CPCs to reserve the right to proof-read the final draft to correct factual errors or misunderstandings;
• What interim reporting arrangements are put in place - how often, in what format and to whom should interim updates be sent and received;
• What timescales are agreed for receipt of the interim and the final report;
• What arrangements are there for reporting any unforeseen delays;
• What arrangements are made between the CPC, as the commissioner and owner of the SCR report, and the review team for speaking to the press regarding the review, and at what stage(s) of the SCR process;
• Who on the CPC has delegated responsibility for handling FOI requests and who the contact should be if the findings of the SCR were to be used as evidence in civil proceedings that might arise out of a case;
• Who will make the links with relevant interests outside the main statutory agencies;
• Who the key contacts are for any review team across all the involved agencies. These could be designated SCR contacts who can also advise on, and broker access to, relevant practitioners and information, provide any agency information that may be relevant (protocols/guidance) and generally act as a liaison point;
• What protocols on confidentiality are specified to which the review team signs up;
• Whether there are likely to be issues of access to case records and how that will be addressed;
• It would be expected of agencies that they will assist the Review team in conducting the Review because the outcome is intended to be a learning document;
• Whether the review team need to conduct interviews or whether it is sufficient for them to look at the files to establish the facts of the case;
• Which agencies and professionals should contribute to the review, and who else should be asked to submit a report or otherwise contribute. This will be based on the chronology of who has been in touch with the child and family/carers;
• Whether family members are to be invited to contribute to the review;
• Who the liaison point for the child (if alive) will be, and/or for their family/carers. CPCs will wish to consider whether it is preferable for this person not to have had prior involvement with the child/family/carers. CPCs will also wish to consider whether it is preferable for this person not to be involved in the SCR investigations;
• Where interviews with contributors will take place;
• What briefing will be provided for contributors, and by whom. A briefing will normally be an oral discussion about the purpose of the Review. CPCs 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;
• What arrangements are in place for feedback to the contributors, including the child and their family/carers, and what mechanism will be used to enable contributors to check the accuracy of what is recorded as it is drafted up for the interim and/or final reports; and
• What procedure will be adopted if the SCR uncovers evidence of criminal acts or civil negligence unrelated to the case under review.

F - Producing, Handling and Delivering the Report

70. Where an SCR has been external, the report is delivered to the commissioning CPC. The CPC should deliver the report to the Chief Officers Group.

71. It is important that there is a degree of consistency to the structure and content of reports. This makes it easier for people to identify and use the findings and for read-across to other reports to be made. The report will include:

• An introduction - summarise the circumstances that led to the review, state the remit and a list of contributors to the review suitably anonymised;
• A separate executive summary and list of recommendations (and who the recommendations are for);
• A chronology of agency/professional involvement;
• The extent of family/carers' involvement;
• A list showing, on each occasion of contact with the child or family/carers or significant adults, whether the child's views and wishes were sought and if they were expressed;
• Analysis;
• Conclusions; and
• Recommendations. These should be few in number, focused, specific and capable of being implemented. It would also be helpful to identify who these are aimed at and any resource implications.

72. The Chief Officers Group should decide to whom full versions of the report are made available. As the SCR report is the key document identifying the issues, the learning points and the good practice found, it would normally be expected that final versions of each report would be published by the CPC (but detailed information on names and circumstances should be anonymised before publication).

73. Even if the Chief Officers Group decide that it does not best serve the public interest nor the purposes of improving service delivery to publish the whole SCR report, it would be always be expected that the Executive Summary and Recommendations would be published. This summary document should be sufficiently detailed to provide a reasonable oversight and analysis of the significant case.

74. It would be expected that an SCR report would be unanimous in its findings and conclusions.

75. The review team and CPC will wish to take account of the requirements of the Freedom of Information Act and Data Protection Act in both the conduct and reporting of the review.

76. The points below, while not exhaustive, highlight the key considerations and responsibilities for clearing and issuing the report of the SCR:

• The CPC must decide how and with whom to share the draft interim and final reports to check for accuracy/other issues;
• The CPC should propose to the Chief Officers Group a distribution list for the full report. This proposed list should have regard to the provisions set out in Section 7;
• The CPC will consider any internal/external communications or briefing required before publication (see Section 7) and advise the Chief Officers Group accordingly; and
• The CPC will consider how media interests will be handled (see Section 7).

G - Follow-Up

77. Having published the report of an SCR, there are a number of issues which CPCs should consider:

• Prepare action and implementation plans and establish a means of monitoring progress;
• Prepare briefing for the Scottish Executive, inspectorates, and others as required;
• Decide on a mechanism for dissemination within and across agencies to capture learning and ensure this is reflected in communication, guidance and training (see Section 8);
• Review the action plan and identification of outcomes;
• Define any actions to be taken if a progress review is not appropriate;
• Agree who will review progress on follow-up activities and when and how this will be done; and
• Provide annual analysis, as a minimum, of all cases referred for a SCR (as well as earlier Initial Case Reviews) to the Scottish Executive, Children & Families Division, Area 2B(North), Victoria Quay, Edinburgh, EH6 6QQ.

H - Family/Carers

78. The family/carers of the child involved should be kept informed of the various stages of the review and the outcomes of these where this is appropriate. Clearly, there will be occasions where the family could be subject to investigation or part of the problem relating to the significant case which triggered the SCR. In these cases information may require to be limited. Close collaboration with the Police and the Procurator Fiscal will be vital.

79. There may also be cases where families are looking to take 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 should not be the responsibility of the CPCs or specifically of the review team.

80. Care should be taken about where and when a child or their family/carers are interviewed. Reviewers should be experienced in communicating with children. It may also be useful to assign a member of staff to be a liaison point throughout the review. The person carrying out this liaison role should be fully aware fully 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.

81. As set out in paras 72-75, the expectation is that the full report will normally be published and that the Executive Summary and Recommendations will always be published. Family/carers and/or other significant adults in the child's life should receive a copy of any report in advance of publication. Consideration should be given as to whether an oral briefing 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.

I - Staff

82. During the review process staff should feel informed and supported by their managers. There may be parallel processes running which staff are involved in (e.g. disciplinary proceedings) as well as the SCR so sensitive handling is important.

83. Each organisation should have its own procedures in place for supporting staff, but below is an illustration of the types of support that could be provided. The line manager should always consider:

• The health and well-being 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;
• The need for legal/professional guidance and support; and
• Time to prepare for interviews and for follow up.

84. This guidance should be given to staff involved in a review, together with a copy of the local operational protocols in place in their CPC area to support this guidance. Once the review has been completed the staff involved in the case should be given a debrief on the review and the findings before the report is published.

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