Child Safeguarding Practice Reviews

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.

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.

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'.

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.

Locally, the Nottinghamshire and the Nottingham City Safeguarding Partnerships have made arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They will commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken.

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.

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. 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.

The identification of serious child safeguarding cases will primarily be through the notification requirements placed on the Local Authority (Nottinghamshire County Council/Nottingham City Council) which require certain incidents (see below) to be notified to the national 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.

Nottinghamshire County Council/ Nottingham City Council will notify the national Child Safeguarding Practice Review Panel of any incident that meets the notification criteria within 5 working days of becoming aware using the approved online notification process. A copy of the notification will be provided to the partnership support office on the same day that it is submitted.

However, any organisation with statutory or official duties in relation to children (including the Child Death Overview Panel - CDOP - and all members of the partnership) should inform the safeguarding partners of any incident which they think should be considered for a child safeguarding practice review.

The partnership support office will arrange for a 'Rapid Review' to be undertaken and completed for:

• All cases notified to them as a result of the notification of incidents process.

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.

As soon as the Rapid Review is complete, the partnership support office will send a copy to the Panel. They will 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.

The Rapid Review will be undertaken and completed within 15 working days and will be coordinated by the Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City). A detailed process for Rapid Reviews has been agreed across Nottingham City and Nottinghamshire. See Additional Resources.

When considering whether to commission a child safeguarding practice review the safeguarding partners will have regard to the definition of a serious child safeguarding case (see Section 1.3, Serious Child Safeguarding Cases above) and the information in the section below.

The criteria which the local safeguarding partners 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 which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate.

When deciding whether to undertake a Child Safeguarding Practice Review the Safeguarding Partners will 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 Integrated Care Board 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.

Meeting the criteria does not mean that the safeguarding partners will automatically carry out a local child safeguarding practice review. The Safeguarding Partners will determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. Decisions on whether to undertake reviews will be made transparently and the rationale communicated appropriately, including to families.

The final decision as to whether the criteria for a child safeguarding practice review is met will be made by senior managers who represent the three safeguarding partners.

Where there are differences of opinion in whether the criteria for a review have been met, the independent scrutineer will be invited to advise and support a further discussion between the partnership representatives. If agreement still cannot be reached, the recommendation of the majority will be followed. The safeguarding partners may consider that a local child safeguarding practice review is appropriate for cases that do not meet the definition of a 'serious child safeguarding case' but nevertheless might reveal learning related to good practice, poor practice or near misses.

The response of the National Child Safeguarding Practice Review Panel to the Rapid Review will be reported back to the safeguarding partners. Should the panel disagree with the decision made by the safeguarding partners the Development Manager (Nottinghamshire)/ Children's Partnership Officer (Nottingham City) will circulate the details of the response and convene a meeting/telephone conference of the safeguarding partners decision makers (i.e. those on the rapid review panel) and the Partnerships' Independent Scrutineer to consider the information provided and review the initial decision. The safeguarding partners, with advice from the Independent Scrutineer, may decide to adhere to their initial decision or conclude that a Local Child Safeguarding Practice Review should be commissioned, in either case the justification should be clearly recorded and provided to the panel.

If the outcome is that the partnership will conduct a local child safeguarding practice review, this will be communicated in writing to the child/family concerned. Where possible this should be provided in person through the practitioner currently working with the family (social worker/police officer) to allow an opportunity for any questions to be raised and responded to.

Each of the safeguarding partnerships will set out a process to ensure periodic audit of the Rapid Reviews undertaken during the previous period to provide assurance to the Strategic Leadership Group that the process is working effectively and that appropriate decisions are being made with a clear rationale.

Nottinghamshire Safeguarding Children Partnership/ Nottingham City Safeguarding Children Partnerships are responsible for commissioning and supervising reviewers for local reviews. This function will be carried out on behalf of the respective partnership by the Child Safeguarding Practice Review Group. When commissioning a reviewer the group will 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.

As soon as they have determined that a local review will be carried out, the Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City) will inform the Panel, Ofsted and DfE, including the name of any reviewer they have commissioned.

This group is chaired by a member of the partnership nominated by the Strategic Leadership Group. The core membership of the group is made up of senior operational managers from the safeguarding partners who act as decision makers for their organisations. Representatives from relevant agencies are invited to contribute to the group depending on the nature of the cases involved. The group will have a flexible approach to their work in order to respond to new cases as they emerge. This will take the form of ad hoc and virtual meetings involving specific members of the group according to needs of particular cases and set meetings to deal with planned work.

Summary of functions:

• Undertake a 'Rapid Review' of cases in accordance with procedures set out in these arrangements;
• Make decisions about whether to undertake a Child Safeguarding Practice Review and agree Rapid Review Reports on behalf of the safeguarding partners;
• Receive details of cases which have undergone a Rapid Review and undertake further analysis when requested by the safeguarding partners;
• Undertake learning reviews;
• Draft terms of reference for Child Safeguarding Practice Reviews;
• Oversee the conduct of Child Safeguarding Practice Reviews;
• Report to the Safeguarding Assurance and Improvement Group (Nottinghamshire)/Business Management Group (Nottingham City) with review findings and pro-posed actions;
• Disseminate learning via the Learning and Workforce and Development group;
• Inform the Safeguarding Assurance and Improvement Group / Business Management Group of any emerging issues and risks.

The Child Safeguarding Practice Review Group will, on behalf of the safeguarding partners, agree with the reviewer(s) the method by which the review should be conducted. All reviews will reflect the child's perspective and the family context. 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.

The safeguarding partners will 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. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

The Child Safeguarding Practice Review Group will advise on the methodology for the review which will have regard to the systems methodology recommended by the Munro Review of Child Protection (May 2011). It is anticipated that the methodology will be tailored to the circumstances of the individual case with an emphasis on achieving the desired learning outcomes in a timely manner.

Where appropriate the Child Safeguarding Practice Review Group will also advise on the following:

• Which organisations are required to contribute chronologies and the timescale for this;
• Consider the requirement for agencies to submit Individual Management Reviews (IMRs) / Reports and the timescales for these;
• Involvement of organisations from other Safeguarding Partnerships in other Local Authority areas;
• Existence and potential impact of parallel processes on the conduct and timing of the review.

As soon as practical after the decision is made to conduct a Child Safeguarding Practice Review, the Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City) will arrange, where necessary, for a briefing session. This will support partner organisations involved in the review to share information, review the terms of reference and the process of the review.

The Child Safeguarding Practice Review Group will supervise the review to ensure that the reviewer is making satisfactory progress and that the review is of satisfactory quality.

The safeguarding partners will, if necessary, request information from the reviewer during the review to enable them to assess progress and quality. Any such requests will be made in writing.

The process of deciding whether a case meets the criteria for a Child Safeguarding Practice Review and the conduct of a review is a statutory one, outlined in Chapter 4 Working Together 2018. The guidance states that "acting in accordance with the safeguarding arrangements requires safeguarding partners and relevant agencies to work together and

• Provide information which enables and assists the safeguarding partners to perform their functions to safeguard and promote the welfare of children in their area, including as related to local and national child safeguarding practice reviews."

The safeguarding partners will 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.

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

Once completed the Review Report will be presented to the Safeguarding Assurance and Improvement Group (Nottinghamshire)/Business Management Group (Nottingham City) for sign off.

Reviews will be completed and published within six months unless there are extenuating circumstances such as an ongoing criminal investigation, inquest or future prosecution. Any delay to the completion or publication of a review will be approved by the Strategic Leadership Group and the reasons notified to the National Child Safeguarding Practice Review Panel and Secretary of State.

When compiling and preparing to publish the report, the safeguarding partners will 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 will 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.

In some circumstances the Strategic Leadership Group may consider it inappropriate to publish a review report, in which case arrangements will be made to publish information about the improvements that should be made following the review. The Strategic Leadership Group will 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.

The Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City) will 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 Strategic Leadership Group decide only to publish information relating to the improvements to be made following the review, they will also provide a copy of that information to the Panel and the Secretary of State within the same timescale. They will also provide the report, or information about improvements, to Ofsted within the same timescale.

The Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City) will be responsible for the publication of Child Safeguarding Practice Reviews or information about the improvements that should be made via the partnership website. The reports/ information will remain on the website for a one year period and thereafter will be available on request. The Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City) will provide the NSPCC with a copy of the report/ information. The NSPCC maintains a national case review repository where case reviews remain available electronically for five years.

Learning and actions for improvement identified from the review process will be disseminated through the locally agreed Learning and Improvement Framework detailed in Learning and Improvement Framework Procedure.

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

The criteria which the Panel must take into account include 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;
• 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;
• Where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings.

If the Panel decides to undertake a national review they will 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.

Any decision by the National Panel to undertake a National Child Safeguarding Practice Review involving a local case will be communicated immediately to the Strategic Leadership Group who will facilitate local cooperation via the Development Manager (Nottinghamshire)/ Children's Officer (Nottingham City).