6.1 Local Child Safeguarding Practice Reviews Framework and Practice Guidance

1. Introduction and Context

1.1 Introduction

The Children and Social Work Act 2017 introduced a legal framework in respect of local safeguarding arrangements for children. Responsibility for how a system learns lessons from serious child safeguarding incidents rests at a national level with the Child Safeguarding Practice Review Panel and at a local level with the three Safeguarding Partners (Integrated Care Boards, Police and Local Authorities) and other partner agencies. They will need to consider whether to conduct a Local Child Safeguarding Practice Review in cases where abuse or neglect of a child is known or suspected, and the child has died or been seriously harmed.

This guidance outlines the process for deciding on and commissioning Local Child Safeguarding Practice Reviews in Buckinghamshire. This makes real the local commitment to an improving and learning system, determined to make best use of resources (human and financial) in the best interests of children and families.

This guidance provides practitioners with a step-by-step guide to follow when undertaking or participating in a Local Child Safeguarding Practice Review. It describes the approach, order of events and related timescales whilst also highlighting the key statutory elements outlined in Working Together to Safeguard Children 2023. It also outlines responsibilities for key people at every stage of the process and references template documents and letters available for use.

1.2 Purpose of local child safeguarding practice reviews

The purpose of a Local Child Safeguarding Practice Review is to explore how practice can be improved through changes to the system itself. Reviews should seek to understand both why mistakes were made and to comprehend whether mistakes made on one case frequently happen elsewhere and to understand why.

Holding organisations and their leaders to account for the quality of services, and individuals to account for not meeting professional standards, are essential pre-requisites for public confidence in the national safeguarding system. Regulatory bodies for the professions hold this key role. Reviews are not designed for this purpose and will not be used in this way. Nevertheless, where reviews identify any actual or potential errors or violations, they should ensure that proper lines of accountability are followed to ensure that those responsible are held to account.

1.3 Definition of a serious child safeguarding case

Working Together to Safeguard Children 2023 defines “Serious child safeguarding cases as those in which:

• abuse or neglect of a child is known or suspected
• the child has died or been seriously harmed.

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. This is not an exhaustive list.”

Working Together to Safeguard Children 2023 advises that “When making decisions, judgement 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.”

Child perpetrators may be the subject of a review, if the definition of a serious child safeguarding case is met.

Working Together to Safeguard Children 2023 states that “The local authority must notify the Secretary of State for Education, and Ofsted of the death of a looked after child. The local authority should also notify the Secretary of State for Education and Ofsted of the death of a care leaver up to and including the age of 24. This should be notified via the Child Safeguarding Online Notification System. The death of a care leaver does not require a rapid review or local child safeguarding practice review. However, safeguarding partners must consider whether the criteria for a serious incident have been met and respond accordingly, in the event the deceased care leaver was under the age of 18. If local partners think that learning can be gained from the death of a looked after child or care leaver in circumstances where those criteria do not apply, they may wish to undertake a local child safeguarding practice review.”

1.4 Criteria for a local child safeguarding practice review

Safeguarding Partners and other partner agencies, as part of the Case Review Group, are required to consider certain criteria and guidance when determining whether to carry out a Local Child Safeguarding Practice Review. They must take into account whether the case:

• 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 the panel has considered and has concluded a local review may be more appropriate.

They should also have regard to circumstances where:

• they have cause for concern about the actions of a single agency
• there has been no agency involvement, and this gives them cause for concern.
• more than one Local Authority, Police area or Integrated Care Board is involved, including in cases where families have moved around
• the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings.

Working Together 2023 highlights that meeting the criteria does not mean a Local Child Safeguarding Practice Review must automatically be undertaken. Instead, the process outlined in this document will be followed to determine whether a review is appropriate (i.e. whether there is potential to identify improvements).

Buckinghamshire Safeguarding Partners and other partner agencies should make sure there is a clear rationale for completing a Local Child Safeguarding Practice Review. Where a Rapid Review has been undertaken (see Section 4.2), it is important that Safeguarding Partners and other partner agencies ensure that the process for undertaking a Local Child Safeguarding Practice Review is a clear ‘step higher’ than a Rapid Review, building on a Rapid Review, and that the learning for practice is more distinctive.

Local Child Safeguarding Practice Reviews may also be undertaken for cases which do not meet the definition of a ‘serious child safeguarding case’ if they raise issues of importance that could generate learning. Working Together 2023, for example, suggests they might take place “where there has been good practice, poor practice or where there have been ‘near miss’ incidents”.

Where the decision made is not to proceed with a Local Child Safeguarding Practice Review, the Safeguarding Partners and other partner agencies will consider whether there are other learning processes that will bring forward improvements.

1.6 Approach and principles

Buckinghamshire Safeguarding Partners have agreed that the approach will be ‘systems based’. Each case will, however, be examined individually to determine the most appropriate methodology to identify and maximise learning.

BSCP will conduct Local Child Safeguarding Practice Reviews in line with good practice and the principles of the systems methodology recommended by the Munro Report. This includes the advice outlined in Working Together to Safeguard Children 2023 and its predecessor documents as well as the good practice principles described in the Social Care Institute for Excellence (SCIE) / NSPCC ‘Quality Markers’.

Decisions on whether to undertake a review will be made transparently and the rationale shared with all relevant partners, including families as appropriate.

The child will always be placed at the centre of the process.

All reviews will be proportionate to the circumstances of the case and focus on the potential learning. Specifically, all reviews will be conducted in a way which:

• reflects the child’s perspective and family context, including the racial, ethnic and cultural background of the child and their family, and other characteristics such as age, gender, disability and sexuality, and explicitly discusses how these characteristics shaped a family’s and child’s lives, experiences, and views, and how practitioners and services responded to them.
• considers and analyses frontline practice as well as organisational structures and learning.
• establishes the reasons why events occurred as they did.
• considers why actions and decisions made sense at the time.
• reaches recommendations that will improve outcomes for children.

Families, including surviving children, will be invited to contribute to reviews unless there is a strong reason not to. Steps will be taken to sensitively manage their expectations and ensure they understand how they are going to be involved.

Practitioners will be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

All participants in the review process will be asked to declare any potential conflicts of interest and will be expected to adhere to confidentiality. This will be a standard agenda item at all case specific meetings.

1.6 Strategic leadership and governance

The decision to proceed to a Local Child Safeguarding Practice Review is always a local decision, for which local Safeguarding Partners are accountable. This includes the identification of cases, commissioning and supervising of reviews, and the publication of reports and embedding learning. Safeguarding Partners should take into consideration advice and guidance provided by the national Child Safeguarding Practice Review Panel.

Buckinghamshire Safeguarding Children Partnerships have Local Child Safeguarding Practice Review Group (LCSPR) which is made up of representatives from the Safeguarding Partners in the area, along with any relevant safeguarding experts from partner agencies. This Group will undertake a Rapid Review when Local Authority notifications of serious incidents are made to the national Child Safeguarding Practice Review Panel. They will also consider other cases referred to them by partner agencies and will take responsibility for commissioning and overseeing any resulting Local Child Safeguarding Practice Reviews. This will include monitoring case progression, quality assurance and publication of final reports, and ensuring effective oversight of the implementation of learning.

All decisions related to the commissioning and publication of Local Child Safeguarding Practice Reviews will be notified to the national Child Safeguarding Practice Review Panel.

2. Information Sharing

Information sharing is essential to safeguard and promote the welfare of children and young people. Effective Local Child Safeguarding Practice Reviews are equally dependent on all relevant partners sharing the information they hold about the case and associated professional practice.

The Safeguarding Partners have the formal authority to request information to support both National and Local Child Safeguarding Practice Reviews and the power to take legal action if information is withheld without good reason.

All agencies will be expected to share relevant information within the timescales requested. This may, when necessary, include sharing information without consent. This includes information about parents, guardians and other family members as well as the child(ren) who are subject of the review.

Where a request is for health records, this applies to all records of NHS commissioned care whether provided under the NHS or in the independent or voluntary sector.

When making requests for information, the Safeguarding Partners and other partner agencies will consider their responsibilities under the relevant legislation and have regard to guidance provided by the Information Commissioner’s Office.

Good practice principles around information sharing will always be followed, particularly around ‘how’ information is shared. For example, when responding to requests for information, agencies should:

• identify how much information to share;
• distinguish fact from opinion;
• ensure that they give the right information to the right individual;
• ensure that they share information securely;
• where possible, be transparent with the individual, informing them that that the information has been shared (as long as doing so does not create or increase the risk of harm);
• record all information sharing decisions and reasons in line with organisational procedures.

In the case of any disagreement or failure to comply with a formal information request, the Reviewer or a Case Review Panel member will refer the issue to the LCSPR Group who will seek to resolve this with the strategic Safeguarding Lead for the agency concerned. If a prompt resolution cannot be found, the issue will be escalated to the Safeguarding Partners for formal action.

3. Timescale for the Completion of the Review

Reviews will vary in their breadth and complexity but, in all cases, learning should be identified and acted upon as quickly as possible. This includes before the review has formally commenced and while it is in progress.

A Rapid Review and decision on all referrals should be made within the timescales outlined in guidance from the national Child Safeguarding Practice Review Panel (currently within 15 working days) and Local Child Safeguarding Practice Reviews should be completed no later than six months from the date of the decision to initiate a review and more quickly if possible.

Sometimes the complexity of a case does not become apparent until the review is in progress. For example, the Police undertaking a criminal investigation may in some instances request the review delay involving specific key individuals. Any delays need to be considered by the relevant Case Review Group as soon as they arise. If the delay will prevent the publication of the final report within six months, the national Child Safeguarding Practice Review Panel and Secretary of State should be informed and provided with the reason for the delay.

4. Deciding when to Convene a Local Child Safeguarding Practice Review

4.1 Notification and referral

Agencies should inform the Buckinghamshire Safeguarding Partnerships Business Unit of any serious incident which they think should be considered for a Local Child Safeguarding Practice Review, using the Referral Form (see Appendices).

Buckinghamshire Council (Children Service) have a separate duty to:

• notify the national Child Safeguarding Practice Review Panel of any incident that meets the criteria in Section 1.4 using the Child Safeguarding Online Notification System. It should do so within five working days of becoming aware it has occurred.
• notify the Secretary of State for Education, and Ofsted of the death of a Looked After Child / Child in Care.
  • although the responsibility to notify the Secretary of State and Ofsted where a Child in Care has died, whether or not abuse or neglect is known or suspected rests on the local authority, it is for all three safeguarding partners to agree which incidents should be notified in their local area.
• notify the Secretary of State for Education and Ofsted of the death of a care leaver up to and including the age of 24. This should be notified via the Child Safeguarding Online Notification System.
  • the death of a care leaver does not require a rapid review or local child safeguarding practice review. However, safeguarding partners must consider whether the criteria for a serious incident has been met and respond accordingly, in the event the deceased care leaver was under the age of 18. If local partners think that learning can be gained from the death of a looked after child or care leaver in circumstances where those criteria do not apply, they may wish to undertake a local child safeguarding practice review.
• where there is disagreement, the safeguarding partners should follow the Escalation, Challenge and Conflict Resolution Procedure.

Where Buckinghamshire Children Services makes a formal notification to the national Child Safeguarding Practice Review Panel, it must always share this with the Partnership Business Office.

A notification by Buckinghamshire Council to the national Child Safeguarding Practice Review Panel will result in a Rapid Review (see Section 4.2).

There will be instances when a referral is made to the LCSPR subgroup by an agency which does not result in a Rapid Review. For example, in a situation where an agency believes a case should be considered by the LCSPR subgroup for a potential Local Child Safeguarding Practice Review, but it does not meet the criteria for a Local Authority Notification to the national Child Safeguarding Practice Review Panel. The formal Referral Form (see Appendices) should be used to make a referral to the LCSPR subgroup in these circumstances.

Where a referral is made by another agency, the Local Authority representative that sits on the LCSPR subgroup will be informed so that they can consider if a notification is required. If it is, the Rapid Review process will be initiated.

The BSCP Business Manager will inform the Partnership Chair of the BSCP and the Chair of the LCSPR Subgroup that a notification has been received.

Where there is no requirement for a Rapid Review, due to the circumstances described above, the following documents can then be used to assist the LCSPR subgroup with obtaining agency information:

• Information Request Letter Should be used to make a request for information to agencies to assist the LCSPR subgroup to discuss potential Local Child Safeguarding Practice Reviews
• Information Request Reply Template Is a template for agencies to record information for the LCSPR subgroup meeting

The LCSPR Subgroup will discuss the case and make a decision if the criteria for a Local Child Safeguarding Practice Review are met. If they are, the national Child Safeguarding Practice Review Panel will be informed, and the Local Child Safeguarding Practice Review process will be followed.

4.2 Rapid Reviews (where a local authority notification has been made)

Rapid Reviews should assemble the facts of the case as quickly as possible in order to establish whether there is any immediate action needed to ensure a child’s safety and the potential for practice learning.

The Rapid Review must be completed within the timescales outlined in guidance from the national Child Safeguarding Practice Review Panel (currently 15 working days of becoming aware of the incident).

See also Local Authority Rapid Review Triage Process (opens as a PDF).

4.3 Initial scoping, information sharing and securing of records

All agencies who have had involvement with the subject child or family will be required to contribute to a Rapid Review. An initial scoping of agencies’ intervention will, therefore, need to be completed and other relevant information will need to be rapidly gathered. To support this, an Information Request Reply Template will be sent out, accompanied by an Information Request Letter. This will be done by the business unit.

The purpose of the initial scoping and information sharing is to gather the basic facts about the case, including determining the extent of agency involvement with the child and family. More detailed information will be sought if the Rapid Review concludes the case has the potential to identify national or local learning and a decision is made to progress to a formal Local Child Safeguarding Practice Review

The Information Request Reply Template should be sent out to all relevant agencies as soon as possible along with an accompanying letter that briefly outlines the notification and explains the purpose of this initial scoping. This should be within 2 working days of receiving the notification.

Agencies should prioritise completion of the template and return it by the deadline included in the letter.

All agencies should consider if they need to secure all records/files in relation to the case, ensuring they are removed to a secure place where they are not accessible to agency personnel other than through a nominated representative.

4.4 Setting the date of the Rapid Review meeting

The Partnership Safeguarding manager will convene a Rapid Review meeting, which will be chaired by the LCSPR subgroup chair.

The date of the Rapid Review meeting should be set as soon as the Information Request has been sent out (see flowchart). The Rapid Review meeting should be scheduled between 7 and 13 working days of receiving the notification. This will allow for analysis of the submitted agency information to establish the key events in the child’s life and inform the Rapid Review whilst also allowing sufficient time to prepare the necessary documents for the national Child Safeguarding Practice Review Panel.

4.5 Documentation

The following documents may be shared with those attending the Rapid Review meeting:

• a copy of the referral;
• a copy of the Combined Summary Report – this is the document used to collect all of the information together and to guide the Rapid Review meeting through the decision-making process.

Wherever possible the documentation will be shared with participants in advance of the meeting. However, it is recognised that it may on occasion be necessary to share documentation at the meeting.

4.6 The Rapid Review meeting

The meeting should include representatives from each of the Safeguarding Partners (the Integrated Care Board, Police and Local Authority) and any other relevant agencies. It will only be quorate if at least three representatives from partner agencies, including at least two of the Safeguarding Partners are present.

The Rapid Review meeting should:

• review the facts about the case as presented in the documentation; • discuss whether any immediate action is needed to ensure child(ren)’s and any other vulnerable person’s safety;
• identify immediate learning that can be acted upon and agree how this will be shared (this may remove the need for further review);
• consider the potential for identifying improvements to safeguard and promote the welfare of children;
• make a decision if a Local Child Safeguarding Practice Review should be commissioned;
• if the decision is to make a recommendation to proceed with a Local Child Safeguarding Practice Review, the meeting should agree on Key Lines of Enquiry (KLOE);
• if the decision is to make a recommendation not to proceed with a Local Child Safeguarding Practice Review, because the criteria are not met or because it is deemed that all learning has been derived from the Rapid Review, the meeting will consider if any dissemination of the Rapid Review learning is appropriate.

If the LCSPR Subgroup feels that information is missing, it may defer a recommendation and adjourn until further information is available and all the facts established. Such a delay may impact on the required timescales for making a decision. Therefore, agencies should ensure they provide full and comprehensive information at the earliest possible opportunity.

4.7 Independent advice on Rapid Reviews and Local Child Safeguarding Practice Review Decisions

The Partnership Chair of the Safeguarding Children Partnership will be sent the information regarding the Rapid Review.

The Chair of the LCSPR Sub Group will put the Sub Group’s recommendation in writing to the Partnership Chair of the BSCP within one month of the notification of the incident using section 2 of the LCSPR Referral Form (see Appendices). Dependent on the outcome of discussions, the recommendation will be one of the following:

• LCSPR to be commissioned;
• criteria for an LCSPR not met- alternative form of learning review recommended;
• criteria for an LCSPR not met – no alternative form of learning review recommended.

This allows the Partnership Chair to provide independent advice, being aware of the discussion that has taken place, but not unduly influencing the main meeting

The Partnership Chair of the BSCP will make his/her decision upon receipt of this recommendation and reply in writing to the Chair of the LCSPR Sub Group using Section 3 of the LCSPR Referral Form (see Appendices).

The Chair of the LCSPR Subgroup will inform the referrer of the Partnership Chair’s decision.

Although the final decision rests with the Chair of the BSCP, the Chair may seek peer challenge from another LSCP Chair when considering this decision and also at other stages in the LCSPR process.

4.8 Sharing the outcome of the Rapid Review

The Business Office will send a Rapid Review Report to the national Child Safeguarding Practice Review Panel ([email protected]).

The Partnership Chair of the BSCP will notify Board members of his/her decision. If the decision is not to initiate a LCSPR or any other type of learning review, Board members will be advised that associated records no longer need to be kept secure

Other agencies (including the agency who made the referral) should also be informed of the outcome of the Rapid Review.

Individual agencies should notify their own inspectorate bodies as required

In cases where the BSCP Chair has decided to initiate a LCSPR, the Chair should provide the National Panel with the names(s) of the reviewer(s) appointed to conduct the LCSPR and the methodology that will be used for the review.

In cases where the BSCP Chair has decided not to initiate a LCSPR, the decision will be subject to scrutiny by the National Panel. The BSCP should provide information to the National Panel on request to inform its deliberations and the Chair of the BSCP should be prepared to attend in person to give evidence to the National Panel.

5. Cases that do not Meet the LCSPR Criteria

The LCSPR Subgroup should consider an alternative form of learning review where the criteria for an LCSPR are not met. A relevant and proportionate methodology should be selected on a case-by-case basis. Examples include:

• Partnership review: The methodologies outlined for an LCSPR could be used or adapted. The LCSPR Subgroup will identify a lead reviewer and determine the terms of reference, timescales and methodology to be adopted. The format and content of information required from agencies will depend on the terms of reference for the review and the agreed methodology. The lead reviewer should produce a report summarising learning. This should be agreed by the LCSPR Subgroup before being submitted to the BSCP.
• Single agency review: This is a review of case that is carried out by an individual agency. When the BSCP Partnership Chair agrees to a recommendation for a single agency review, he/she will write to the Board Member or Lead for Safeguarding in the relevant agency recommending that a single agency should be undertaken. The findings of the single agency review should be shared with the LCSPR Subgroup before being submitted to the BSCP.
• Auditing of practice (single or multi-agency): In some cases, the LCSPR Sub Group may feel that an audit of practice would be appropriate. Where a multi-agency audit is recommended, the Partnership Chair of the BSCP should ask the Chair of the Performance and Quality Assurance Sub Group (P&QA) to lead this work. Where a single agency audit is recommended, the BSCP Chair will write to the agency concerned and ask them to report their findings to the P&QA Subgroup.

As with LCSPRs, the BSCP through the LCSPR subgroup will monitor the implementation of actions resulting from these reviews and reflect on progress in its annual report.

6. Process for Conducting a Local Child Safeguarding Practice Review

The process will vary depending on the methodology being used.

The LCSPR Panel should aim for completion of an LCSPR within six months of initiating. If this is not possible (for example because of potential prejudice to related court proceedings), every effort should be made to ensure this does not prevent any learning being captured and any corrective action being taken.

7. Appointing an Independent Reviewer

Dependent on the methodology used to undertake a Local Child Safeguarding Practice Review, a Reviewer may be appointed to manage the review process, chair meetings of the Case Review Panel, facilitate the Learning Workshops and author the final report.

Where an LCSPR is being conducted, the reviewer must be independent of the BSCP, of partner organisations involved in the case and from professionals and LCSPR Panel members involved in the case.

The reviewer must have demonstrated that they are qualified to conduct reviews using the principles set out in Working Together to Safeguard Children 2023 and in line with the agreed review methodology.

The reviewer will be commissioned by the BSCP Business Manager in accordance with the BSCP’s standard contract for Independent Authors.

The reviewer is responsible for:

• reading and analysing agency chronologies, reports and information to identify key issues and learning;
• writing an overview report to set out the learning, including appropriate and proportionate recommendations for action, and, where agreed, an executive summary;
• dependent on the methodology being used, the author may also have a role in designing and facilitating learning events and seeking the views of family members.

In producing the overview report, the reviewer should:

• consider all information submitted to the Panel;
• ensure that, wherever possible, the views/experience of the child and their family are incorporated into the findings;
• ensure that the views/experience of staff and managers who were involved in the case are taken into account;
• ensure that the reports anonymise the child, family members and staff using the codes agreed by the Panel;
• ensure the overview report is based on fact and is open, honest and transparent;
• ensure that recommendations are clear, robust and SMART (Specific, Measurable, Attainable, Relevant, Time-bound);
• ensure the report fulfils the terms of reference for the review.

In producing the final draft, the reviewer should satisfy the LCSPR Panel that all issues raised by the Panel have been addressed.

8. Appointing a Local Child Safeguarding Practice Review Panel Chair

The LCSPR Subgroup should recommend a suitable person to act as Chair for the LCSPR Panel. This can be someone from a local agency as long as that agency was not involved in the case. The Chair should have relevant skills taking into account the specific issues in the case.

The LCSPR Panel Chair is responsible for:

• ensuring the LCSPR Panel operates effectively so that organisations and agencies collaborate to produce a comprehensive and timely LCSPR which identifies the lessons to be learned and establishes a framework to ensure they are learned;
• ensuring all those involved in the review are clear of the purpose of the LCSPR, the process to be applied, and of their individual roles, responsibilities and tasks;
• ensuring agency reports are quality assured;
• liaising with the LSCP Business Manager and Chair to agree a revised timescale if the statutory timescale is unlikely to be met;
• ensuring the draft report is considered against the agreed Terms of Reference to ensure that they have been fulfilled;
• ensuring that the final report is comprehensive, well written and meets the requirements of Working Together to Safeguard Children 2023;
• ensuring the views of all panel members are heard and given equal weight during the review so that robust dialogue can take place.

The LCSPR Panel Chair and BSCP Business Manager should ensure that:

• expert advice is available to the LCSPR Panel if required;
• objectivity and challenge are applied throughout the process;
• the final report is entirely and consistently anonymised with no loss of meaning and that all information remains confidential;
• progress is managed robustly to meet statutory deadlines and agreed timescales;
• legal advice is available to the panel via the BSCP legal adviser;
• the BSCP Partnership Chair is kept up to date on the progress of the review;
• action is taken to investigate and attempt to resolve any disputes or issues of non-compliance by participating agencies – where necessary any ongoing disagreements or challenges which arise during the LCSPR process should be referred to the LSCP Chair;
• the independent reviewer has all the necessary information and act as a point of contact for the reviewer should any questions arise.

9. The Case Review Panel

Where appropriate a small, multi-agency Case Review Panel will be established to oversee each review. This will include a representative from each of the Safeguarding Partners along with representatives of any other multi-agency partners. Other relevant subject matter experts may be included depending on the case.

The Case Review Panel will support the Reviewer in quality assuring agency Information Reports and facilitating Learning Workshops. The Panel will also provide local context and challenge to the analysis of professional practice and the identification of learning.

The Police representative will be responsible for liaising with the Senior Investigating Officer, Crown Prosecution Service, and for co-ordination of family liaison.

9.1 Setting up an LCSPR Panel

The LCSPR Subgroup will identify initial panel members. Panels should include senior representatives of the agencies involved in the case or specialists in the professions involved. These representatives should be independent of the case under review, having had no direct management involvement and must have sufficient seniority to be able to comment on their agency’s practice. The panel may also include representatives from other non-involved partner agencies to ensure further independence and support for the LCSPR process. Legal advice should be available to the Panel via the BSCP legal adviser, who may sit as a member of the Panel or, where appropriate, provide advice to the Panel where required. The panel may also co-opt additional members in relation to specific issues that arise during the LCSPR process.

Panel members should not also be responsible for writing agency reports as this could lead to a conflict of interest and prejudice their independence.

The expectation is that membership of the Panel will remain constant. Agencies should ensure that sufficient time is allocated to enable the representative to effectively undertake the work of the LCSPR Panel.

The membership of the Panel may need to be extended, once the terms of reference have been established.

9.2 Role of the LCSPR Panel

The LCSPR Panel is collectively responsible for the quality, effectiveness and timeliness of the review. The specific functions of the panel are:

• determine the scope of the review, draw up clear terms of reference and keep these under review throughout the LCSPR process;
• select the time period over which events are reviewed and consider whether these may need to be reviewed in the light of any new information provided. Where families have been known to agencies for many years a summary of involvement prior to recent years may be sufficient to allow the review to concentrate on the detail of recent events;
• set a clear timescale for the completion of the review and plan review activity so that this timescale will be met;
• aim to complete the review within six months, including planning for any anticipated delays, ensuring that any delays are kept to a minimum and where there are delays this does not hinder the learning process;
• identify the agencies and professionals that need to provide information;
• ensure that appropriate knowledge and expertise for the case is represented in the membership of the panel;
• ensure that all staff are supported to participate in the review, including taking specific responsibility for making sure staff in their own agency understand the tasks that are required of them;
• scrutinise and challenge reports provided by agencies to ensure they adhere to the terms of reference, are based on sound evidence and reasoned findings and to identify gaps in knowledge or resolve conflicting information;
• request additional information and ensure reports are clear and of a high quality;
• ensure the child’s experience is kept at the centre of the process;
• consider how best to notify and involve relevant family members;
• agree and implement arrangements for anonymity;
• consider the impact of parallel processes, e.g. criminal investigations or disciplinary procedures;
• agree arrangements for working with other LSCPs where necessary;
• take account of any legal advice provided to the Panel;
• ensure that report authors selected by their respective agencies are sufficiently independent from the case;
• ensure that any learning is translated into action plans and that reports and action plans take account of any learning that has already been implemented (see Action Plan Template; opens in Word);
• ensure the overview report considers all aspects of the terms of reference;
• ensure the overview report fully consider the information contained in agency reports;
• ensure the evidence, analysis and findings presented by the Overview Author receive robust scrutiny and are challenged where necessary to ensure a credible and influential conclusion for the review;
• ensure that the overview report is written in a style that is understandable for both professionals and the general public.

For more information see, Child Safeguarding Practice Review Panel Guidance for Partners (Publishing Services .Gov.uk)

10. Agreeing the Scope and Terms of Reference

10. Developing the terms of reference

The development of the Terms of Reference (TORs) will be dependent on the specific methodology employed to review an individual case. The LCSPR subgroup should have an early input into the Terms of Reference.

If a Case Review Panel is set up to manage the specific review, they will have the responsibility of completing the Terms of Reference at an early stage of their first meeting. If a Reviewer is commissioned, they will also be involved in the development of the Terms of Reference. Any issues raised by the Case Review Panel or Reviewer that cannot be resolved will be referred to the LCSPR subgroup for a decision.

• The preliminary LCSPR Panel must agree terms of reference to ensure the review incorporates all relevant issues. These should be sent to the Partnership Chair of the BSCP for approval.
• Time spent on this part of the process is crucial and will affect the quality of reports and, ultimately, lessons arising from the overview report.
• Better outcomes can be achieved if everyone involved in the LCSPR addresses the same questions and issues pertinent to the case. Consequently, the terms of reference will be incorporated into all report templates.

The initial scope and terms of reference for the review may need to be revised if significant new information emerges during the review, e.g. they might identify other key agencies/organisations involved or they might indicate that the timeframe for the review needs to be adjusted to allow focus on a particular period.

The LCSPR subgroup will formally agree the scope and Terms of Reference for the review.

10.2 Scoping period

The scoping period covered by the review should reflect the potential learning likely to be achieved. (There is little value in identifying weaknesses in professional practice or procedures that have already changed). It should, therefore, be as short and as recent as possible. This, however, needs to be balanced against the need to understand the pattern of child abuse or neglect and whether early help interventions could have been beneficial.

10.3 Focus of the review

The Rapid Review is likely to identify the key lines of enquiry to be explored as part of the review. These will be confirmed and formally identified in the Terms of Reference. These may, however, be revised as more information becomes available. Any significant changes should be formally approved by the Case Review Group.

10.4 Methodology

Each case will be examined individually, and the methodology will be adapted to meet the specific needs of the case.

The Terms of Reference will specify the methods of information collection and collation tools that will be used in the review. This may include Chronologies (of key events and/or organisational changes), Information Reports or a combination of these (see Section 15, Methodology for more information).

10.5 Engaging children and family members

Using the information available, and the genogram where available, consideration will be given to which family members are relevant to the review and how the family, siblings and the child (where the review does not involve a death) should be invited to contribute.

The information and support that children and family members are likely to require to effectively engage will also be identified.

Plans to engage children and family members will need to take into account any parallel investigations. For more information see Section 14, Engaging with Children and Families.

11. Parallel Investigations

The case may also be subject to a criminal or coroner’s investigation, individual agency or professional body disciplinary procedures, and/or another type of formal review.  It is anticipated that a Local Child Safeguarding Practice Review will go ahead unless there are clear reasons not to. Identifying and responding to learning in a timely manner is important and supports a more effective review.

Under Working Together to Safeguard Children 2023 there is greater discretion as to when a Local Child Safeguarding Practice Review should take place and who does it. This enables greater flexibility in designing the right review methodology whilst meeting statutory obligations. Where there are parallel investigations, this is best considered at the scoping stage to reduce duplication and the impact on children and families and maximise learning.

12. Legal Advice

Consideration will be given to whether legal advice will be required at the outset or during the review.

13. Timetable

Taking into account the factors summarised above, the timetable for the review will be agreed. This will include the timing of Case Review Panel meetings, Learning Events and engagement with families.

14. Engaging with Children and Families

14.1 Approach and principles

Working Together to Safeguard Children 2023 highlights the crucial importance of inviting families, including surviving children, to contribute to reviews. This will help ensure that the review reflects the child’s perspective and the family context.

In line with good practice, consideration will be given to how family members can be supported to engage. This may include interpretation and translation support if English is not a first language, additional support for disabled parents, specialist support where there are issues of domestic abuse, and drawing on expertise to facilitate the appropriate involvement of children.

Family engagement will be included as a standing item at all Case Review Panel meetings. The Panel will also identify an individual who will take responsibility for co-ordinating communication with family members.

14.2 Identifying the family network

The lead agency working with the child/family will usually be asked to prepare a full and accurate genogram to assist the clarification of family relationships and dynamics. This will be shared with other agencies at Panel meetings and in the Reflective Learning Workshop (see Section 15.9) and will be updated based on any additional information on the family provided by these agencies. The genogram will not be in the final published report with any names included.

14.3 Making initial contact with the family

Family members, including surviving children, will be informed of the review and invited to contribute unless there is a strong reason not to do so. The Case Review Panel will discuss family involvement and agree an approach that will sensitively manage their expectations and ensure they understand the process.

Personal contact should be made whenever possible by the most appropriate practitioner and the family provided with a letter (where required, signed for or hand delivered by an appropriate practitioner such as the social worker) and/or leaflet to explain and introduce the process and Reviewer.

14.4 Conversations with family members

Family engagement will normally be led by the Reviewer and conversations should ideally take place before the Learning Event (see Section 15.9) so that the family’s views can be included alongside the analysis of practice.

It is recognised that family members may decide not to take part in the review. All reasons for non-involvement of family members (for example, parallel investigations or the choice of the individual) will be documented in the final report.

15. Methodology

15.1 The ‘Systems Methodology’ and expectations of agencies

Working Together to Safeguard Children 2023 does not specify the methodology that should be used in Local Child Safeguarding Practice Reviews but there is an explicit expectation that “principles of the systems methodology recommended by the Munro Report” will be “taken into account” by the Safeguarding Partners and other partner agencies when agreeing the method by which the review will be conducted.

This section describes the systems-based approach. This is consistent with both the guidance in Working Together to Safeguard Children 2023, and the principles of the systems methodology recommended by the Munro Report.

Each case will be examined individually, and the methodology may be adapted to meet the specific needs of the case, to ensure a proportionate response, and to maximise learning to improve both frontline safeguarding practice and organisational structures. For some cases, the Safeguarding Partners and other partner agencies may agree to use a different methodology.

15.2 Agency action and expectations

All agencies which provided services to the family during the time period specified in the Terms of Reference will be formally requested to participate in the review process. The extent of agency engagement will be dependent on the type of review commissioned, the specific Terms of Reference and methodology chosen.

Each organisation should have an identified Safeguarding Lead to act as a single point of contact for the co-ordination and support of the review process.

Agencies should ensure that all requests for information are acted upon in a timely fashion and practitioners are released to participate in the review. Agencies should also provide support to their staff who are affected by the case where required.

15.3 Information collection and collation

The Terms of Reference will specify the information collection and collation tools that will be used in the review. Information will usually be collected using chronologies and Information Reports.

15.4 Chronologies

Where chronologies are used, all relevant agencies will be asked to complete a chronology of their agency’s involvement in relation to significant events that are relevant to the case. They may also be asked to produce a chronology of any organisational changes which may have impacted on frontline practice during the same period. If required, chronologies can include columns to provide analysis of individual events, including if an agency’s response to an event was expected practice.

Agencies will be sent a Chronology Template and Accompanying Letter, along with Guidance on Completing the Chronologies.

Individual agency chronologies will be collated to produce a Multi-Agency Chronology.

15.5 Information Reports

Information Reports will be requested from agencies where required in order to analyse the agency’s involvement with the child and family and any themes that have emerged. The report should be focused on systems learning and outline any potential learning for the agency and for multi-agency arrangements and should include information about actions already undertaken.

Agencies will be sent an Information Report Template and Accompanying Letter, along with Guidance on Completing an Information Report.

15.6 Factual summaries

If an agency / organisation has had contact with a subject of a Local Child Safeguarding Practice Review or their family, but their involvement was limited, and no significant incidents have taken place during their contact or as a result of their contact, they may be asked to complete a Factual Summary. This sets out their agency / organisation’s involvement without requiring any analysis of the agency’s involvement.

15.7 Quality assurance of agency submissions

The Case Review Panel, chaired by the Reviewer, needs to be satisfied that the appropriate level of information has been provided by each agency and that the analysis provides sufficient insight into the actions undertaken by the agency and possible learning.

If necessary, the Panel may decide to either request more information from an individual agency or invite them to attend a meeting if further clarity is needed about their agency’s role with the child and/or family.

15.8 Establishing key themes

Using the chronologies and/or analysis in the Information Reports, the Panel will discuss the case in detail and develop the key themes for analysis. These should be as few as practicable and focus on core learning. The key themes should identify issues of practice that have emerged within the case which can (i) be transposed into working with families more generally and (ii) give insight into the systems which operate formally or informally within safeguarding practice. Some examples might be “making space and time for children” or “the use of assessments to inform future interventions”.

The key themes for analysis may be shared with participants prior to their attendance at the Reflective Learning Workshop.

15.9 Reflective Learning Workshop

Reflective Learning Workshops provide a forum for practitioners involved in the case and their Line Managers to come together in a respectful, positive and supportive environment to consider the circumstances surrounding the case and the reasons why actions were taken. This enables the Reviewer and Panel to explore factors influencing workers working with the family at the time, their decisions and identify important multi-agency learning.

A Reflective Learning Workshop will not be suitable for all reviews. In some cases, the key individuals who had worked with children and families will have left the agencies that they had been employed by at the time of their involvement with a case.

15.10 Preparing for the Learning Workshop

The Panel will need to ensure it has a list of appropriate practitioners and their Line Managers to invite to the Learning Workshop. This will usually be requested alongside the chronology and/or Information Report.

To maximise learning all agencies are expected to ensure that appropriate staff attend the workshop. However, only those who have had some form of direct operational involvement with the child and family should attend.

An Invitation to the Reflective Learning Workshop will be sent to all participants giving plenty of notice. This will be accompanied by a short briefing which explains the purpose of the event and the importance of attending.

15.11 The Structure of the Learning Workshop

The Reflective Learning Workshop will normally be undertaken over half a day, although a more complex case may require an additional half day.

The Reviewer will normally facilitate the Reflective Learning Workshop, supported by members of the Panel.

The structure of the Workshop will vary depending on the case but is likely to include a discussion of:

• the information compiled about the family in terms of incidents and professional interventions with an opportunity for participants to query the factual accuracy, to add information and to agree changes;
• the “lived experience of the child/children”. This enables participants to view what happened from the child’s perspective;
• the reasons why events and practice happened the way they did, including any organisational and ‘systems’ factors that may have shaped behaviour (such as organisational/team aims or culture, levels of supervision, or the resources available to deliver services);
• the key themes which have emerged in the case and whether they can be transposed to working with families more generally; and
• any examples of good practice, the learning from the case and actions that should be taken to better safeguard children in the future.

Within these discussions it is essential that all actions and decisions (or lack of them) by professionals are viewed within the context of the information available at the time and system in which they were working.

The Reviewer will assist the group to avoid hindsight bias in their consideration of what took place.

15.12 Conversations with key practitioners

Where an individual with important information to contribute to the review is unable to participate in a Reflective Learning Workshop, arrangements may be made to facilitate a conversation with the Reviewer to enable them to contribute to the learning.

16. The Report

It is expected that reports will be published so the Reviewer should draft the formal report with publication of the report in mind.

Reports should meet any requirements specified in the agreed Terms of Reference for the review and, as a minimum, should also succinctly include:

• an overview of what happened and the key circumstances, background and context of the case. This should be concise but sufficient to understand the context for the learning and recommendations;
• a description of the methods used in completing the review, with sufficient detail to explain what was done and how;
• analysis against the key lines of enquiry;
• a clear picture of the child’s daily life;
• analysis of how sensitive practice was to race, ethnicity, religion, culture, gender, disability, sexual orientation and other protected characteristics (as defined in the Equality Act);
• information on direct work with children and families – for example, how often workers from all professional backgrounds met them, how long they spent with them, what they observed, what they talked about, what explanations the families gave and why the workers responded as they did;
• analysis of how direct practice was shaped by context and systems (workloads, availability of other services, training, supervision and team culture);
• a summary of why relevant decisions by practitioners were taken;
• analysis of how agencies worked together and any shortcomings in this;
• whether any shortcomings identified are features of practice in general;
• what would need to be done differently to prevent harm occurring to a child in similar circumstances;
• examples of good practice;
• the views of the child(ren) and family, unless there are compelling reasons not to do so; findings from practitioners’ events;
• reference to published research relating to themes and learning identified and consideration of other recent cases in the locality and nationally as comparisons; • findings which are contextualised with other reports, inspections and audits, to get a broader understanding of practice and organisational challenges;
• what needs to happen to ensure that agencies learn from this case and meaningful learning for the multi-agency partnership; and
• a limited number of focused, realistic recommendations, which can then be translated into specific and achievable action plans (‘SMART’ plans).

Reports should be written in a way that avoids harming the welfare of any children or vulnerable adults in the case. Information should be appropriately anonymised and very intimate and personal detail of the family’s life should be kept to a minimum to reduce the sensitivity of publication.

The Case Review Panel will be responsible for ensuring the quality of the draft report has met the agreed Terms of Reference, is succinct and focused on improving local safeguarding arrangements.

The final report must be formally approved by the relevant Case Review Group followed by the Safeguarding Children Partnership.

16.1 Developing the findings and recommendations

The analysis of the information collected during the review, coupled with the feedback from a Reflective Learning Workshop, should lead to the identification of key learning in the form of specific findings in the report.

These findings may be developed into formal recommendations that will form part of the final report. Buckinghamshire Safeguarding Children Partnership may choose to convene a dedicated group to consider the learning and how this can be developed into meaningful actions.

In some cases, Buckinghamshire Safeguarding Children Partnership may decide at the outset of a review that the identified findings in the report will be considered by a separate group who will identify what action needs to be taken to address a specific finding.

Whichever approach is taken; Buckinghamshire Safeguarding Children Partnership will be able to engage key strategic stakeholders and consider the potential learning in the context of wider operational and strategic developments. This will ensure that actions are focused on the issues that will make a real difference and, therefore, maximise the opportunity to deliver meaningful change.

In all cases, learning will be focused on improving outcomes for children and should be clear about what is required of relevant agencies and others collectively and individually, and by when.

17. Publication

17.1 Requirements

The Safeguarding Partnership is required to publish the reports of Local Child Safeguarding Practice Reviews, unless they consider it inappropriate to do so.

Working Together to Safeguard Children 2023 states that all reviews of cases meeting the LCSPR criteria should result in a report which is published and readily accessible on the BSCP’s website for a minimum of 12 months. Thereafter, the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing LCSPRs.

If an LSCP considers that a LCSPR report should not be published, it should inform Ofsted, the Department for Education and the national Child Safeguarding Practice Review Panel, which will provide advice to the LSCP. The LSCP should provide all relevant information to the National Panel on request to inform its deliberations.

Publication of SMART multi-agency action plans, arising from the recommendations of the review (or a clear statement of why the partnership does not accept them), should also be considered. These should be published alongside the Local Child Safeguarding Practice Review, for accountability and as a sign of the partnership’s commitment to learning and improvement.

17.2 Preparing for publication

Publication will be considered throughout the review process and media planning will commence as soon as the final draft report has been formally endorsed by the Case Review Group and Safeguarding Children Partnership. Publication planning will include strategic leads from all the agencies involved in the review and their media/communication leads.

Buckinghamshire Safeguarding Children Partnership should publish, either as part of the LCSPR report or in a separate document, information about:

• actions which have already been taken in response to the review findings;
• the impact these actions have had on improving services what more will be done.

LSCPs must comply with the Data Protection Act 2018 in relation to LCSPRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders.

17.3 Managing the impact of publication

Consideration will be given to how best to manage the impact of the publication on children, family members, practitioners and others closely affected by the case.

The wishes of the child’s family will be considered as part of the publication and media planning. The proposed publication arrangements will then be discussed with the family and appropriate steps will be taken to minimise the disruption and distress that any media attention surrounding the publication may cause to family and friends.

The arrangements for informing practitioners will also be considered. It is likely that the senior managers from each agency will take responsibility for informing frontline staff of the date of publication and ensuring they have appropriate support.

17.4 Media strategy

All media enquiries regarding LCSPRs must be referred to the Independent Chair of the BSCP via the BSCP Business Manager.

A central point of contact for media enquiries should be identified. This individual can coordinate media enquiries during the publication phase and ensure effective liaison is maintained with each organisation’s strategic and media leads.

The BSCP will ensure that a media strategy is developed in advance of publishing an LCSPR, including, where appropriate, an agreed statement which will be shared with relevant partners. The BSCP will liaise with the local authority’s Communications Team and nominated media contacts of relevant partner agencies prior to publication to ensure all relevant parties are fully briefed.

Any media enquiries relating to services or individuals associated with an LCSPR should also be discussed with the BSCP Partnership Chair to ensure that consistent and clear messages are provided in a co-ordinated response.

17.5 Formal publication

Working Together to Safeguard Children 2023 states that “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 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.”

The Safeguarding Children Partnership must send a copy of the full report to the National Panel, Ofsted and to the Department of Education no later than seven working days before the date of publication. Reports should be submitted electronically to:

• [email protected]
• [email protected]
• [email protected]

Published reports will always include the name of the reviewer(s) and will be made available to read and download from the appropriate Safeguarding Children Partnership website, unless these are published anonymously. Reports will be publicly available for at least one year. Archived reports will be available on request from the Safeguarding Children Partnership, through the relevant Business Office.

On a case-by-case basis, it will be considered if published reports will also be submitted for inclusion in the NSPCC National Repository of Safeguarding Case Reviews. Reports will be submitted by email to: [email protected]

18. Embedding Learning

18.1 Purpose

The purpose of a Local Child Safeguarding Practice Review is to identify improvements that can be made to safeguard and promote the welfare of children. Disseminating and embedding the learning is, therefore, crucial.

18.2 Capturing improvements and taking action while the review is in progress

The Panel will consider at every meeting whether any immediate single or multi-agency action is required to respond to emerging issues identified through the review process. They may wish to deliver swift messages to the workforce in specific agencies or disseminate multi-agency learning to a wider workforce. In so doing, the Panel will consider what information is shared and whether this will have an impact on family members or any parallel investigations.

18.3 Disseminating and sharing learning from the review

Buckinghamshire Safeguarding Children Partnership will be responsible for ensuring the identified improvements are implemented locally, including the way in which organisations and agencies work together.

A clear plan for disseminating and sharing the learning from the review with all relevant agencies will be developed. This may include organising single or multi-agency meetings or producing briefing notes on the lessons learned for use in agency team meetings and/or supervision sessions.

It is the responsibility of the agencies who have participated in the review to ensure their agency recommendations are fully implemented and used to make improvements to their safeguarding children arrangements and information on this and the impact of improvement is reported o the Safeguarding Children Partnership.

Methods for sharing LCSPR learning include:

• During the LCSPR process
  • Discussion and reflection in interviews undertaken by report authors with staff involved in the case.
  • Discussion and debate at LCSPR panel meetings
  • Fast-tracking of significant issues to the BSCP and/or individual agencies throughout the review process, e. not delayed until outcome of review
  • Learning events held with the practitioners involved in the case
  • Feedback and consultation with relevant family members.

• After the LCSPR process
  • Presentation and discussion of learning points at the Safeguarding Board
  • Dissemination of learning points through dedicated briefing or learning sessions, team meetings, training events or newsletters.
  • The incorporation of lessons learned across BSCP training, policies, procedures and guidance documents, performance and quality assurance activity.
  • Publication of overview report on the BSCP website
  • Sharing learning points across LSCP networks through regional forums
• The LCSPR Sub Group is responsible for agreeing and overseeing BSCP activity to disseminate learning, although it may be appropriate for this to be done through joint working across Sub Groups.

18.4 Monitoring progress

The Quality Assurance Subgroup will regularly audit progress on the implementation of recommended improvements and will regularly monitor and follow up actions to ensure improvement is sustained. This will be via the Buckinghamshire Safeguarding Children Partnership Multiagency Safeguarding Arrangements.

The BSCP section 11 audit will allow the BSCP to gain assurance around how individual agencies disseminate learning from LCSPRs and other forms of review within their own agency. Where necessary, the LCSPR Sub Group may also ask agencies to provide additional information.

18.5 Learning from national reviews

 The LSCPR Subgroup will also review the learning from all national reviews and consider how it can be applied at a local level.

20. Local involvement in National Reviews

The Child Safeguarding Practice Review Panel decides whether it is appropriate to commission a National Child Safeguarding Practice Review, as set out in Working Together to Safeguard Children 2023. They state that “The national reviews we commission may be thematic reviews based on types of cases or systemic issues that we see frequently or are identified as important national issues, or they may be individual case reviews where a particular case is significant in terms of its complexity or implications for national learning.”

The Child Safeguarding Practice Review Panel also states: “An important part of setting up the review process is a dialogue between the Panel and the local areas affected. This helps make sure the scope and methodology of the review maximises the learning potential and the most efficient of resources, including the time of those involved at a local level. Where the Safeguarding Children Partnership receives a request around a National Child Safeguarding Practice Review, the Statutory Partners and, subsequently, the Case Review Group will be informed about the request and the parameters. The Chair of the Case Review Group will be the main point of contact, and the Business Office will help facilitate any information required / local agency attendance at meetings.

Appendices

Referral Form – to share serious incidents for consideration by the Rapid Review Panel (opens in Word)

Action Plan Template (opens in Word)