Child Practice Reviews – resources for practitioners

Child Practice Reviews (CPR) or Serious Case Reviews (SCR) play a vital role in helping practitioners and organisations to continually improve the way they work, individually or together, to keep children and young people safe and free from harm.

A Review is the formal process that brings together information from all the agencies involved with a child and their family leading up to the incident. From these records, a complete picture of the case can be drawn up in a report, which includes analysis of all contact with the child and family, any decisions that were made, the conclusions made and any recommendations for action.

When and why do Reviews take place?

Reviews are carried out for every case where abuse or neglect is known or suspected and either:

  • a child has died or;
  • a child has been seriously harmed and there are concerns about how organisations or professionals worked together to protect the child.

The full criteria are specified in Working Together to Safeguard Children 2018.

A Review should always be carried out when a child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or secure children’s home.

The same applies where a child dies who was detained under the Mental Health Act 1983, or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

Why do Reviews take place?
The purpose of Reviews is to identify improvements which are needed and to consolidate good practice. Reviews are not enquiries into how a child died or was seriously harmed, or into who is to blame. These are matters for the coroners and criminal courts as appropriate.

Reviews identify improvements to practice to safeguard and promote the welfare of children by:

  • establishing what lessons need to be learned from the case about the way in which professionals and organisations work individually and together to safeguard and promote the welfare of children;
  • identifying clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
  • improving intra- and inter-agency working to better safeguard and promote the welfare of children.

The findings from Reviews are translated into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.

Safeguarding Partnerships (formerly Local Safeguarding Children Boards) have a duty to publish an anonymised version of the Review Report. This will include an overview of the case, the terms of reference, conclusions drawn and any recommendations made.

Review reports are published for a minimum of twelve months; all reports published prior to this should be available from the NSPCC Case Review Repository.

Reviews are a major element of our learning and improvement framework which sets out how we will learn lessons from tragic events and put in place measures to reduce the likelihood of such events reoccurring. Working Together 2018 requires us to publish information about actions which have been taken in response to the findings of Reviews.

MSP Review Referral Process 

If an individual or agency feels a case should be referred for a Review they should complete the most current version of the MSP Rapid Referral template – Children and partner agencies are asked to contribute any information they may have about the case. This is then screened by the Case Review Subgroup to determine if it meets the criteria.

If you become aware of an incident or case:

  • discuss it with a senior manager and/or your agency Case Review Subgroup member
  • if required, your agency Subgroup member or a senior manager should hold an initial discussion with the MSP Coordinator
  • the Subgroup member or senior manager should complete the Review Referral form and submit it to the MSP by email 

Carrying out MSP Reviews

Reviews are led by an independent reviewer who has no connection to the case, or to the organisations whose actions are being reviewed.

Practitioners involved with the child or family in the case are fully involved in Reviews. They are invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

Families are also invited to contribute to Reviews. We work hard to make clear to them how they are going to be involved and mange their expectations appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.

Reviews should be conducted in a way which:

  • recognises the complex circumstances in which professionals work together to safeguard children;
  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
  • is transparent about the way data is collected and analysed; and
  • makes use of relevant research and case evidence to inform the findings.

Resources for practitioners involved in a Review 

Practitioners should contact the MSP for support and advice about being part of the review process.

The MSP Review event guidance for practitioners can be given to practitioners asked to attend a learning event.

Resources for families involved in a Review 

It is essential that families are made aware that a Review is taking place and that they are offered the opportunity to contribute to the review process. Early discussions will be needed with the child or young person, family and friends (identified as appropriate by the Review Panel) and they should be informed of concerns and that a Review is underway.

Information for families about the Review process can be found on the MSP Briefing note on CPR for families (Oct 2019).

Published Reviews

We publish our Reviews online for twelve months; all current and historical Review publications can be found in the NSPCC National Case Reviews Repository

Most recently published reports:

All media enquiries relating to the publication of Reviews should be made to the MSP Business Unit

Published Review Learning Packs

Learning packs for completed Reviews are made available on the website as soon as practicable and often prior to publication. These can be used by individual agencies for internal cascading within their organisation to make sure that the valuable lessons learned are shared across staff teams.

Supporting learning events are advertised on our training website.

Child E1 SCR: Learning event held April 2018; report not published

Child F1 SCR: Learning event held April 2018; full report published 15.05.2018

Child G1 SCR: Learning event held September 2017; full report published 15.05.2018

Child H1 SCR: Learning event held October 2017; full report published 14.12.2017

Child I1 SCR: Learning event held November 2017; full report published 14.12.2017

Child J1 SCR: Learning event held  December 2017; report not published

Child K1 SCR: Learning event May 2018; full report published 14.12.2017

Child L1 SCR: Learning event held May 2018; full report published 15.05.2018

Child M1 SCR: Learning event held October 2018; full report published 20.08.2018

Child N1 SCR: Learning event held September 2018; full report published 15.11.2018

Child O1 SCR: Learning event and full report to be published in 2019

Child P1 SCR: Learning event and full report to be published in 2019

Child Q1 SCR: Learning event and full report to be published in 2019

National Learning from Reviews

NSPCC thematic briefings
The NSPCC produces a useful series of briefing papers containing findings from Case Reviews against various themes – these can be found on their website at www.nspcc.org.uk

National Panel of Independent Experts 
The National Panel of Independent Experts was established to ensure that appropriate action is taken to learn from serious cases and to ensure that lessons learned are shared through publication of the final Review report find out more at www.gov.uk/serious-case-review-panel

NSPCC National Case Reviews Repository

The NSPCC National Case Reviews Repository was launched in 2013. The repository provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.

The repository is accessible via the NSPCC library online  and has over 800 case reviews and inquiry reports dating back to 1945.

The NSPCC website has further information about the Repository, research on case reviews and a list of all learning from case review briefings.

Practitioners can:

  • sign up direct for alerts from the NSPCC website
  • obtain a list of reports held in the Repository for a LSCB, Partnership or topic:
    • open the NSPCC library catalogue
    • under Advanced search
    • select Publisher from the Search in drop-down menu
    • enter the relevant name in the Search terms box e.g. Manchester
    • select Case reviews from the Media type drop-down menu.

Legislation and guidance 

Reviews are conducted under the guidance of Working Together To Safeguard Children 2018 .

The Association of Independent LSCB Chairs website publishes a number of useful document and links; these include advice relating to the publication of anonymised Reviews.

 

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