Chapter 4: Improving child protection and safeguarding practice

Contents

Overview
Purpose of child safeguarding practice reviews
Responsibilities for reviews
Duty on local authorities to notify incidents to the Child Safeguarding Practice Review Panel
Decisions on local and national reviews
The rapid review
Guidance for the national Child Safeguarding Practice Review Panel
Commissioning a reviewer or reviewers for a local child safeguarding practice review
Local child safeguarding practice reviews
Expectations for the final report
Actions in response to local and national reviews
Guidance for the Child Safeguarding Practice Review Panel – reviewers
The Panel – expectations for the final report

Overview

1.

Child protection in England is a complex multi-agency system with many different organisations and individuals playing their part. Reflecting on how well that system is working is critical as we constantly seek to improve our collective public service response to children and their families.

2.

Sometimes a child suffers a serious injury or death as a result of child abuse or neglect. Understanding not only what happened but also why things happened as they did can help to improve our response in the future. Understanding the impact that the actions of different organisations and agencies had on the child’s life, and on the lives of his or her family, and whether or not different approaches or actions may have resulted in a different outcome, is essential to improve our collective knowledge. It is in this way that we can make good judgments about what might need to change at a local or national level.


Purpose of child safeguarding practice reviews

3.

The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policy- makers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.

4.

Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage. Employers should consider whether any disciplinary action should be taken against practitioners whose conduct and/or practice falls below acceptable standards and should refer to their regulatory body as appropriate.


Responsibilities for reviews

5.

The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel (the Panel) and at local level with the safeguarding partners.

6.

The Panel is responsible for identifying and overseeing the review of serious child safeguarding cases which, in its view, raise issues that are complex or of national importance. The Panel should also maintain oversight of the system of national and local reviews and how effectively it is operating.

7.

Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They must commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken.

8.

The Panel and the safeguarding partners have a shared aim in identifying improvements to practice and protecting children from harm and should maintain an open dialogue on an ongoing basis. This will enable them to share concerns, highlight commonly-recurring areas that may need further investigation (whether leading to a local or national review), and share learning, including from success, that could lead to improvements elsewhere.

9.

Safeguarding partners should have regard to any guidance which the Panel publishes. Guidance will include the timescales for rapid reviews (see paragraph 20) and for the Panel response.

10.

Serious child safeguarding cases are those in which:

  • Abuse or neglect of a child is known or suspected; and
  • The child has died or been seriously harmed.

11.

Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health[75]. This is not an exhaustive list. When making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred.

[75] Child perpetrators may also be the subject of a review, if the definition of ‘serious child safeguarding case’ is met.


Duty on local authorities to notify incidents to the Child Safeguarding Practice Review Panel

16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) states:

Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if –

  1. The child dies or is seriously harmed in the local authority’s area; or
  2. While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.
12.

The local authority must notify any event that meets the above criteria to the Panel[76]. They should do so within five working days of becoming aware that the incident has occurred. The local authority should also report the event to the safeguarding partners in their area (and in other areas if appropriate[77]) within five working days.

13.

The local authority must also notify the Secretary of State and Ofsted where a looked after child has died, whether or not abuse or neglect is known or suspected.

14.

The duty to notify events to the Panel rests with the local authority. Others who have functions relating to children[78] should inform the safeguarding partners of any incident which they think should be considered for a child safeguarding practice review. Contact details and notification forms for local authorities to notify incidents to the Panel are available from the notification to Ofsted page on Gov.uk[79].

[76] Online notifications to the Panel will be shared with Ofsted (to inform its inspection and regulatory activity) and with DfE to enable it to carry out its functions.
[77] If, for example, the event relates to a looked after child who has been placed out of area.
[78] This means any person or organisation with statutory or official duties or responsibilities relating to children.
[79] This form will be replaced later in 2018 with a new notification system.


Decisions on local and national reviews

15.

Safeguarding partners must make arrangements to:

  • Identify serious child safeguarding cases which raise issues of importance in relation to the area; and
  • Commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken.

16.

When a serious incident becomes known to the safeguarding partners[80], they must consider whether the case meets the criteria for a local review.

17.

Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. Issues might appear to be the same in some child safeguarding cases but reasons for actions and behaviours may be different and so there may be different learning to be gained from similar cases. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families.

18.

Safeguarding partners must consider the criteria and guidance below when determining whether to carry out a local child safeguarding practice review.

The criteria which the local safeguarding partners must take into account include whether the case[81]:

  • Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified;
  • Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children;
  • Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children;
  • Is one which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate.

[80] Safeguarding partners should also take account of information from other sources if applicable.
[81] The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018.

Safeguarding partners should also have regard to the following circumstances:

  • Where the safeguarding partners have cause for concern about the actions of a single agency;
  • Where there has been no agency involvement and this gives the safeguarding partners cause for concern;
  • Where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around;
  • Where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings[82].
[82] Includes children’s homes (including secure children’s homes) and other settings with residential provision for children; custodial settings where a child is held, including police custody, young offender institutions and secure training centres; and all settings where detention of a child takes place, including under the Mental Health Act 1983 or the Mental Capacity Act 2005.
19.

Some cases may not meet the definition of a ‘serious child safeguarding case’, but nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near miss’ events. Safeguarding partners may choose to undertake a local child safeguarding practice review in these or other circumstances.


The rapid review

20.

The safeguarding partners should promptly undertake a rapid review of the case, in line with any guidance published by the Panel. The aim of this rapid review is to enable safeguarding partners to:

  • Gather the facts about the case, as far as they can be readily established at the time;
  • Discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately;
  • Consider the potential for identifying improvements to safeguard and promote the welfare of children;
  • Decide what steps they should take next, including whether or not to undertake a child safeguarding practice review.
21.

As soon as the rapid review is complete, the safeguarding partners should send a copy to the Panel[83]. They should also share with the Panel their decision about whether a local child safeguarding practice review is appropriate, or whether they think the case may raise issues which are complex or of national importance such that a national review may be appropriate. They may also do this if, during the course of a local child safeguarding practice review, new information comes to light which suggests that a national review may be appropriate. As soon as they have determined that a local review will be carried out, they should inform the Panel, Ofsted and DfE, including the name of any reviewer they have commissioned.

[83] The Panel may share this with DfE if requested, to enable DfE to carry out its functions.


Guidance for the national Child Safeguarding Practice Review Panel

22.

On receipt of the information from the rapid review, the Panel must decide whether it is appropriate to commission a national review of a case or cases. They must consider the criteria and guidance below.

The criteria which the Panel must take into account include whether the case[84]:

  • Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified;
  • Raises or may raise issues requiring legislative change or changes to guidance issued under or further to any enactment;
  • Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children.

The Panel should also have regard to the following circumstances:

  • Significant harm or death to a child educated otherwise than at school;
  • Where a child is seriously harmed or dies while in the care of a local authority, or while on (or recently removed from) a child protection plan;
  • Cases which involve a range of types of abuse[85];
  • Where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings[86].
[84] The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018
[85] For example, trafficking for the purposes of child sexual exploitation.
[86] Includes children’s homes (including secure children’s homes) and other settings with residential provision for children; custodial settings where a child is held, including police custody, young offender institutions and secure training centres; and all settings where detention of a child takes place, including under the Mental Health Act 1983 or the Mental Capacity Act 2005.
23.

As well as considering notifications from local authorities and information from rapid reviews and local child safeguarding practice reviews, the Panel should take into account a range of other evidence, including inspection reports and other reports and research. The Panel may also take into account any other criteria they consider appropriate to identify whether a serious child safeguarding case raises issues which are complex or of national importance.

24.

In many cases there will need to be dialogue between the safeguarding partners and the Panel to support the decision-making process. The safeguarding partners must share further information with the Panel as requested.

25.

The Panel should inform the relevant safeguarding partners promptly following receipt of the rapid review, if they consider that:

  • A national review is appropriate, setting out the rationale for their decision and next steps;
  • Further information is required to support the Panel’s decision-making (including whether the safeguarding partners have taken a decision as to whether to commission a local review).

26.

The Panel should take decisions on whether to undertake national reviews and communicate their rationale appropriately, including to families. The Panel should notify the Secretary of State when a decision is made to carry out a national review.

27.

If the Panel decides to undertake a national review they should discuss with the safeguarding partners the potential scope and methodology of the review and how they will engage with them and those involved in the case.

28.

There will be instances where a local review has been carried out which could then form part of a thematic review that the Panel undertakes at a later date. There may also be instances when a local review has not been carried out but where the Panel considers that the case could be helpful to a national review at some stage in the future. In such circumstances, the Panel should engage with safeguarding partners to agree the conduct of the review.

29.

Alongside any national or local reviews, there could be a criminal investigation, a coroner’s investigation and/or professional body disciplinary procedures. The Panel and the safeguarding partners should have clear processes for how they will work with other investigations, including Domestic Homicide Reviews, multi-agency public protection arrangements reviews or Safeguarding Adults Reviews, and work collaboratively with those responsible for carrying out those reviews. This is to reduce burdens on and anxiety for the children and families concerned and to minimise duplication of effort and uncertainty.


Commissioning a reviewer or reviewers for a local child safeguarding practice review

30.

The safeguarding partners are responsible for commissioning and supervising reviewers for local reviews[87].

31.

In all cases they should consider whether the reviewer has the following:

  • Professional knowledge, understanding and practice relevant to local child safeguarding practice reviews, including the ability to engage both with practitioners and children and families;
  • Knowledge and understanding of research relevant to children’s safeguarding issues;
  • Ability to recognise the complex circumstances in which practitioners work together to safeguard children;
  • Ability to understand practice from the viewpoint of the individuals, organisations or agencies involved at the time rather than using hindsight;
  • Ability to communicate findings effectively;
  • Whether the reviewer has any real or perceived conflict of interest.

[87] Safeguarding partners may also consider appointing reviewers from the Child Safeguarding Practice Review Panel’s pool of reviewers where available.


Local child safeguarding practice reviews

32.

The safeguarding partners should agree with the reviewer(s) the method by which the review should be conducted, taking into account this guidance and the principles of the systems methodology recommended by the Munro review[88]. The methodology should provide a way of looking at and analysing frontline practice as well as organisational structures and learning. The methodology should be able to reach recommendations that will improve outcomes for children. All reviews should reflect the child’s perspective and the family context.

[88] The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011).

33.

The review should be proportionate to the circumstances of the case, focus on potential learning, and establish and explain the reasons why the events occurred as they did.

34.

As part of their duty to ensure that the review is of satisfactory quality, the safeguarding partners should seek to ensure that:

  • Practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • Families, including surviving children, are invited to contribute to reviews. This is important for ensuring that the child is at the centre of the process[89]. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

35.

The safeguarding partners must supervise the review to ensure that the reviewer is making satisfactory progress and that the review is of satisfactory quality. The safeguarding partners may request information from the reviewer during the review to enable them to assess progress and quality; any such requests must be made in writing. The President of the Family Division’s guidance covering the role of the judiciary in SCRs[90] should also be noted in the context of child safeguarding practice reviews.

[89] Morris, K., Brandon, M., and Tudor, P., (2013) ‘Rights, Responsibilities and Pragmatic Practice: Family participation in Case Reviews'.
[90] President of the Family Division’s Guidance covering the role of the judiciary in serious case reviews.


Expectations for the final report

36.

Safeguarding partners must ensure that the final report includes:

  • A summary of any recommended improvements to be made by persons in the area to safeguard and promote the welfare of children;
  • An analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report.
37.

Any recommendations should be clear on what is required of relevant agencies and others collectively and individually, and by when, and focussed on improving outcomes for children.

38.

Reviews are about promoting and sharing information about improvements, both within the area and potentially beyond, so safeguarding partners must publish the report, unless they consider it inappropriate to do so. In such a circumstance, they must publish any information about the improvements that should be made following the review that they consider it appropriate to publish. The name of the reviewer(s) should be included. Published reports or information must be publicly available for at least one year.

39.

When compiling and preparing to publish the report, the safeguarding partners should consider carefully how best to manage the impact of the publication on children, family members, practitioners and others closely affected by the case. The safeguarding partners should ensure that reports are written in such a way so that what is published avoids harming the welfare of any children or vulnerable adults involved in the case.

40.

Safeguarding partners must send a copy of the full report to the Panel and to the Secretary of State no later than seven working days[91] before the date of publication. Where the safeguarding partners decide only to publish information relating to the improvements to be made following the review, they must also provide a copy of that information to the Panel and the Secretary of State within the same timescale. They should also provide the report, or information about improvements, to Ofsted within the same timescale.

[91] ‘Working day’ means any day which is not a Saturday, Sunday or Bank Holiday.

41.

Depending on the nature and complexity of the case, the report should be completed and published as soon as possible and no later than six months from the date of the decision to initiate a review. Where other proceedings may have an impact on or delay publication, for example an ongoing criminal investigation, inquest or future prosecution, the safeguarding partners should inform the Panel and the Secretary of State of the reasons for the delay. Safeguarding partners should also set out for the Panel and the Secretary of State the justification for any decision not to publish either the full report or information relating to improvements. Safeguarding partners should have regard to any comments that the Panel or the Secretary of State may make in respect of publication.

42.

Every effort should also be made, both before the review and while it is in progress, to (i) capture points from the case about improvements needed, and (ii) take corrective action and disseminate learning.


Actions in response to local and national reviews

43.

The safeguarding partners should take account of the findings from their own local reviews and from all national reviews, with a view to considering how identified improvements should be implemented locally, including the way in which organisations and agencies work together to safeguard and promote the welfare of children. The safeguarding partners should highlight findings from reviews with relevant parties locally and should regularly audit progress on the implementation of recommended improvements[92]. Improvement should be sustained through regular monitoring and follow up of actions so that the findings from these reviews make a real impact on improving outcomes for children.

[92] See also Chapter 3 Multi-agency safeguarding arrangements, Reporting (safeguarding partners’ report).


Guidance for the Child Safeguarding Practice Review Panel – reviewers

44.

The Panel must set up a pool of potential reviewers who can undertake national reviews, a list of whom must be publicly available. If they consider that there are no potential reviewers in the pool with availability or suitable experience to undertake the review, they may select a person who is not in the pool. When selecting a reviewer, the Panel should consider whether they have any conflict of interest which could restrict their ability, or perceived ability, to identify improvements impartially.

45.

For national child safeguarding practice reviews, the Panel should follow the same guidance on procedure and supervision as for local child safeguarding practice reviews (paragraphs 32-35).


The Panel – expectations for the final report

46.

The Panel must ensure that the final report includes:

  • A summary of any improvements being recommended to the safeguarding partners and/or others to safeguard and promote the welfare of children;
  • An analysis of any systemic or underlying reasons why actions were taken or not taken in respect of matters covered by the report.

47.

The Panel must publish the report, unless they consider it inappropriate to do so. In such a circumstance they must publish any information about the improvements that should be made following the review that they consider it appropriate to publish. The name of the reviewer(s) should be included.

48.

The Panel should work with safeguarding partners to identify and manage the impact of the publication on children, family members, practitioners and others closely affected by the case.

49.

The Panel must ensure that reports or information published are publicly available for at least three years. The Panel must send a copy of the full report to the Secretary of State no later than seven working days before the date of publication. Where the Panel decides only to publish information relating to the improvements to be made following the review, they must also provide a copy of that information to the Secretary of State within the same timescale. The Panel should also send a copy of the report or improvements to the relevant safeguarding partners, Ofsted, the Care Quality Commission and Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services.

50.

Reports should be completed and published within six months of the date of the decision to initiate a review. Where other proceedings may have an impact on or delay publication, for example an ongoing criminal investigation, inquest or future prosecution, the Panel should advise the Secretary of State of the reasons for the delay. The Panel should also set out for the Secretary of State the explanation for any decision not to publish either the full report or information relating to improvements. During the review, the Panel should share any points that arise about improvements needed with the safeguarding partners in any local authority areas covered by the review and others as applicable.

51.

The Panel should send copies of published reports of national and local child safeguarding practice reviews, or published information relating to improvements that should be made following those reviews, to the What Works Centre for Children’s Social Care and relevant inspectorates, bodies or individuals as they see fit. Where a local review results in findings which are of national importance, or in recommendations for national government, the Panel should consider the potential of those recommendations to improve systems to safeguard and promote the welfare of children and how best to disseminate and embed such learning.