1. Scrutiny Panel Serious Case Review Group Activity and outcomes April 2013 - September 2014 Keith Ibbetson Independent Chair SCR Group

2. Overview Revised statutory guidance published April 2013 –Working Together to Safeguard Children 2013 Serious Case Reviews seen as part of a continuum of methods for learning and improvement What happened? Why? What can be learnt to avoid similar incident? Identify underlying weaknesses in arrangements, not just faults in individual cases Greater flexibility of methodology National Panel of Independent Experts – role in challenging decision making of LSCB chair

3. Criteria for SCR Abuse or neglect is known or suspected and either –Child dies –Seriously harmed and there are concerns about how agencies worked together to safeguard the child Decision making not always straightforward –Cause and circumstances of death –Nature of harm –Extent of concerns about professional practice View from the expert panel

4. Alternatives to SCR Partnership case reviews –Have used a number of methodologies Commission reviews in single agency Proportionate, independent and timely learning In every case – an action plan led by single agency or LSCB with evidence of improvement

5. Referrals and outcomes 2013 - 14 Three serious case reviews signed off by LSCB –One published (a highly unusual case where no one had identified concerns) –Two awaiting publication Death of young patient with eating disorder Serious injuries to a disabled chil d Partnership reviews Care leaver living out of the county Injured infant Single agency review (mental health trust) Suicide of young psychiatric patient

6. Priority concerns arising from the reviews Examples of services not functioning under sustained pressure –Either newly commissioned or established –Partner agencies and LSCB not sighted so not able to act to mitigate risk or challenge Professional understanding of risks in adult behaviour not fully informing assessment of child Culture of professional acceptance of adult accounts with insufficient challenge

7. Priority concerns arising from the reviews Services for children with disabilities –Range of levels of need and family views –Status as ‘child in need’, role of social care and arrangements for coordination and review of services –Communication with children with disabilities –Recognition of neglect and abuse among children with disabilities

8. Referrals and current work 2014 - 15 Qualitatively different cases and concerns: Two current SCRs –Deaths of two children –Substantial agency involvement –Recent contact and assessment of the family –Number of agencies involved Possible further SCR depending on outcome of post mortem and police enquiries Partnership case review on care leaver who was killed (living away from Herts and away from family) Learning positive lessons - following an unavoidable death where services have done everything correctly

9. Recurring themes Vulnerability of care leavers Vulnerability of children with disabilities The purposefulness and effectiveness of inter- agency working Understanding of thresholds and capacity / competence of agencies –What level of intervention is needed? –Making decisions on correct information –Escalation and challenge when the system appears not to be responding properly

10. Issues to reflect on A number of the issues from the last presentation re-occur –Purposeful information sharing and multi-agency working –Interface between services dealing with adult behaviour and children’s services ‘Wicked’ problems not easily resolved given complexity of systems, repeated change and pressure on resources Forthcoming cases may attract adverse attention