Scottish Government

1. INTRODUCTION

1. Recommendation 6 of the Audit and Review of Child Protection It's Everyone's Job to Make Sure I'm Alright¹ asked for the Scottish Executive to "consult on how child fatality reviews should be introduced in Scotland. This should include consultation on how they should be conducted, how review teams should be constituted, to whom they would report and what legislative framework is required to ensure their effectiveness". This guidance is the product of the consideration that has been given by the Scottish Executive and its partners to delivering that recommendation.

2. Reviews of significant cases are already undertaken by agencies involved in child protection, whether singly or jointly, although there is no standard approach to when and how these are tackled. Local areas and individual agencies will have their own processes and procedures in place but across Scotland there is a degree of inconsistency in how decisions are made on:

• when to call for a review;
• what type of review to hold;
• the management of the process;
• the skills and expertise required to undertake the review;
• the reporting requirements of the review; and
• the implementation of the review's findings.

3. This guidance should help provide more clarity and consistency on what should be done and how best to act on the lessons learnt from a Significant Case Review ( SCR), both locally and across Scotland.

Purpose of the Guidance

4. The purpose of the guidance is to provide a systematic and transparent approach to the review process. The overarching objectives of a review are to:

• Establish whether there are lessons to be learnt about how better to protect children and young people and help ensure children get the help they need when they need it in the future - reviews should be understood as a process for learning and improving service as well as a means of recognising good practice;
• If and when appropriate, make recommendations for action (albeit that immediate action to improve service or professional shortcomings need not await the outcome of a formal review);
• Consider how any recommended actions will be implemented;
• Address the requirement to be accountable, both at the level of the agency/agencies and the occupational groups involved;
• Increase public confidence in public services, providing a level of assurance about how those services acted in relation to a significant case about a child; and
• Identify national issues where appropriate including good practice.

5. This guidance supports these objectives by helping those considering undertaking a review, or actually doing so, to:

• Undertake the review at the level which is necessary, reasonable and proportionate;
• Adopt a consistent, transparent and structured approach;
• Identify the skills, experience and knowledge that are needed in the review process and consider how these might be obtained;
• Address the needs of the many different people and agencies who may have a legitimate interest in the process and outcome; and
• Take account of the evidence bases.

6. A review may reveal staff actions or inactions which are of sufficient seriousness that they need to be brought to the attention of the employer. The reviewing body has a duty to do this, irrespective of the SCR process.

Who is this Guidance for?

7. Protecting children and young people is an inter-agency and inter-disciplinary responsibility. While it is social work services who usually lead on the discharge of local authorities' legal responsibilities in respect of safeguarding children ², any agency (including voluntary sector organisations) or profession may be the initiator of the review process detailed here.

8. Nevertheless, in every case, it is the local inter-agency Child Protection Committee ( CPC) - which works on behalf of the Chief Officers in health, police and the local authority in that area - which has overall responsibility for the formal review of a significant case. It is the CPC, on behalf of the Chief Officers Group, which decides whether an SCR is warranted; the manner in which the review is conducted; and then either undertakes the review itself or commissions it to be done externally (although ownership always ultimately remains with the CPC). This guidance is therefore targeted at CPCs.

9. CPCs are not constituted as statutory bodies, but are comprised of membership drawn from statutory and voluntary agencies. The authoritative role CPCs play in handling an SCR stems from the requirements placed on them in Protecting Children and Young People: Child Protection Committees³, where CPCs are required to:

• Undertake a range of multi-agency functions including taking the decision on whether to proceed to an SCR; and
• Subsequently manage the review process, including its communications, report handling and follow through.

10. In addition, one of the Quality Indicators ( QI 5.4) for the joint inspection of child protection services ⁴ uses the example of an SCR to illustrate how senior managers and the CPC must "actively and systematically take a leading role in ensuring improvement both within and across services."

11. This guidance should also prove relevant to all those involved in the delivery of children's services, including those working in the voluntary and independent sector. From time to time, they may be involved in contributing to an SCR.

The Status of a Significant Case Review ( SCR) Relative to Other Linked Investigations

12. There are sometimes reasons why a review cannot be easily progressed or concluded, e.g. where there is an ongoing criminal investigation or where there are links to a Fatal Accident Inquiry or Children's Hearings Proceedings (see Annex 1 for kinds of formal investigation). Section 9 considers this in more detail. Criminal investigations always have primacy. To help establish what status an SCR (including the Initial Case Review) should have relative to other formal investigations there should be ongoing dialogue with the police, Procurator Fiscal or others to determine how far and fast the SCR process can proceed in certain cases. Good local liaison arrangements are important. Issues to be considered include how to:

• Link processes;
• Avoid witness contamination;
• Avoid duplicate information being collected; and
• Decide whether a parallel process should mean that an SCR should be adjourned.

13. Regardless of whether or when an SCR takes place, it is important that any obvious areas for improvement of practice identified by the immediate evidence should be addressed as soon as possible. Following the death of a child or the identification of serious concerns relating to a child, agencies should immediately assess the circumstances of the case to identify if there are any immediate actions that need to be taken. If action is required, it should be proportionate and taken at local level as far as possible.

14. It is important that the review process which this guidance sets out is carried out in good time - not least to reduce stress on the child (if they are still living); their family or carers; and the staff of the agencies involved in the SCR.