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Serious Case Review

Introduction

This guidance explains:

  • what a Serious Case Review (SCR) is;
  • how a SCR is conducted; and
  • the CPS's role.

SCRs are usually for cases involving children, but they may sometimes be used to review cases involving vulnerable adults.

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Serious Case Review: children

A Serious Case Review (SCR) is a locally conducted multi-agency review in circumstances where a child has been abused or neglected, resulting in serious harm or death and there is cause for concern as to the way in which the relevant authority or persons have worked together to safeguard the child.

Local Safeguarding Children Boards (LSCBs) are set up by local authorities in accordance with section 13 of the Children Act 2004. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.

Regulation 5(1) (e) and 5(2) set out a LSCB's function in relation to SCRs.

  • paragraph (5) (1) (e) relates to undertaking reviews of serious cases and advising the authority and their Board partners, on lessons to be learned.
  • paragraph 5(2) explains that, for the purposes of paragraph (1)(e), a case is considered to be serious when:
    1. abuse or neglect of a child is known or suspected; and
    2. either -

      (i) the child has died; or

      (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

The purpose of a SCR is not to reinvestigate or apportion blame, but to:

  • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;
  • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and,
  • improve cross agency working and better safeguard and promote the welfare of children.

A SCR will usually draw upon information obtained from:

  • interviewing family members;
  • interviewing significant people who may have known the victim; and,
  • obtaining information from participating agencies, either by way of an Individual Management Review (IMR), attendance at meetings or by other means such as a chronology of events.

SCRs are not inquiries into how a child died or was seriously harmed, or into who is culpable. These are matters for coroners and the criminal courts to determine as appropriate.

Where the homicide victim was aged between 16 and 18, a child SCR should be conducted and take precedence over a Domestic Homicide Review (DHR). The underlying principles for a SCR equally apply to a DHR.

Chapter 4 of Working Together to Safeguard Children (2013), published by the Department for Education, sets out the processes that LSCBs should follow when undertaking SCRs. CPS staff involved in a SCR should ensure they are aware of the guidance.

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SCR Panel Membership

The core membership of LSCBs is set out in sections 13(3) and (4) of the Children Act 2004, and includes:

  • local authority services for education;
  • social services for children;
  • health bodies;
  • the police.

The power to involve other organisations is provided in sections 13(5) and (6).

The LSCB should ensure that there is appropriate representation, in the review process, of professionals and organisations who were involved with the child and family. The priority should be to engage organisations in a way which will enable important factors in the case to be identified, and appropriate action taken to make improvements. The LSCB may decide, as part of the SCR, to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review.

The CPS is not one of the statutory members but falls into the category of 'other organisations' which the LSCB needs to link to, either through inviting them to join the LSCB, or through some other means. Given the circumstances and age of the victim subject to a SCR, it is likely that the CPS will be asked to participate in a SCR and CPS Areas should refer to the section on 'Factors to Consider' (below) for how to respond if invited to participate.

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Process

Cases which meet one of the criteria (i.e. regulation 5(2) (a) and (b) (i) or 5 (2) (a) and (b) (ii) - as set out above) must always trigger an SCR. But, even if one of the criteria is not met an SCR should always be carried out when:

  • a child dies in custody, in police custody, on remand or following sentencing;
  • in a Young Offender Institution, in a secure training centre or a secure children's home; or,
  • where the child was detained under the Mental Capacity Act 2005. Regulation 5(2) (b) (i) includes cases where a child died by suspected suicide.

Where a case is being considered under regulation 5(2) (b) (ii), unless it is clear that there are no concerns about inter-agency working, the LSCB must commission a SCR. The final decision on whether to conduct the SCR rests with the LSCB Chair. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review.

The police play a key role on the LSCB and will provide the CPS with a point of contact on these issues. It is therefore essential that effective communication between the CPS and the police is maintained throughout the process.

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Simultaneous SCR and criminal proceedings

The LSCB Chair should ask the police and the CPS (if appropriate) for advice on how the review should take account of any criminal investigation or criminal proceedings. They should also ask what potential impact a review may have upon such investigations or proceedings, including whether a review should not start until after the proceedings are completed or, if the SCR is already underway, whether it should be delayed until after the outcome of the criminal proceedings. Following any criminal proceedings, the SCR should be concluded without delay.

The SCR is independent from the criminal justice process and it is not possible to enforce demands that the timescales or methodology of the SCR is altered. The subject matter of each SCR, the identity of the agencies contributing to it, and the disclosure issues to which it gives rise will differ considerably from case to case. The dates on which police enquiries and SCRs begin and end relative to each other will also vary in different cases. However, if there is concern that the SCR will jeopardise ongoing criminal investigations or proceedings, there should be discussion and agreement reached with the LSCB chair on the way forward.

Additionally, the Review Panel may wish to interview the victim's family and friends for the purposes of a SCR whilst a criminal investigation or criminal proceedings are ongoing. This is potentially of critical importance, as in many cases there will be great deal of pressure placed upon those responsible for a SCR to conclude a timely review. It is imperative that if a criminal investigation is on-going, or criminal proceedings have commenced, the Senior Investigating Officer informs the CPS and Review Panel if any interviewees are potential witnesses, and again there should be urgent discussion on the way forward including whether the SCR should be delayed exceptionally until the criminal proceedings have been completed.

The National Policing (formerly ACPO) Child Death Working Group, together with the CPS, have drafted useful practical guidance which may be of assistance to prosecutors. The "Liaison and information exchange when criminal proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews - A Guide for the Police, Crown Prosecution Service and Local Safeguarding Children Boards" (May 2014) can be read here.

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Invitation to participate in a SCR

There is no compulsion for the CPS to participate in a SCR. However, if a CPS Area is approached to participate in a SCR, it is expected that the Chief Crown Prosecutor or Deputy Chief Crown Prosecutor should contact the Chief Operating Officer with details of the request that has been made.

An invitation to participate in a SCR will come from the Chair of the LSCB addressed to the relevant CPS Area. The invitation may be to invite a senior member of the CPS Area:

  • to be a member of the Review Panel; or
  • to contribute to the review process, e.g. by the submission of an Individual Management Review (IMR), which is an account of an agencies involvement in the case.

The statutory guidance does not specify how contact should be made with the CPS. However, as a general rule, as the local SCR teams will be responsible for the running of the review, they will decide on how contact is to be made. Recipients of invitations are advised to verify that they are genuine, and should use secure methods for communicating where available.

Factors to consider

As a starting point, Areas should contact the Chair of the LSCB and request details, so that an assessment can be made whether to participate or not.

Requests to participate as a SCR panel member should be considered positively where there is a specific reason associated with the case which requires a response from the CPS (for example, where the homicide occurred whilst the defendant was on bail, or if there had been a previous decision to not charge a defendant). It is likely that panel members will be required to attend a number of meetings and such invitations should be assessed on a case by case basis. Alternatively, participation by the CPS may be required as an opportunity to explain our role and decision making process in a particular case.

Once informed of a SCR, the relevant CPS Area should ensure that steps are taken to secure any records relating to the current case and previous related cases. Where files have been destroyed due to passage of time or a decision not to charge, the police should be contacted for any records they may have.

The CPS should usually agree to participate in the SCR process, particularly when the CPS role may have been misunderstood and leading to the possibility of erroneous conclusions. Where the CPS has had previous involvement in respect of the case in question, Areas should consider participating in the SCR so that we can explain CPS's role and the application of the Code for Crown Prosecutors in the decision making process. Accordingly, those attending a SCR should have full knowledge of the case, be able to explain the actions and clarify the role of the CPS and should have the appropriate seniority and experience.

When considering whether to participate consideration must be given to:

  • the fact that a case may be sub judice;
  • the danger of inadvertent disclosure of confidential information;
  • possible prejudice to the trial process as a result of information given or received including evidence;
  • the need to retain objective prosecutorial independence;
  • how to deal with actual or perceived criticism of decisions by the CPS to prosecute (or not); and,
  • how to deal with issues that extend beyond the circumstances of the particular case.

It should be remembered that it is not the role of the CPS to comment upon prevention and protection issues, unless the death under review has had criminal justice input prior to the offence, e.g. where a defendant was on bail when the homicide occurred.

There may be instances where the CPS is not invited to be part of the SCR process but are then referred to within the SCR by another agency. In such cases it would be appropriate for the CPS to make enquiries of the panel and either offer to be involved, or request a copy of the report for accuracy before it is published and suggest amendments if appropriate to do so.

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Individual Management Reviews (IMRs)

An IMR is an account of an agencies role in how they dealt with a particular case. The aim of an IMR is to:

  • allow agencies to look openly and critically at individual and organisational practice and the context within which people were working to see whether the homicide indicates that changes could and should be made;
  • identify how those changes will be brought about; and
  • identify examples of good practice within agencies.

There is no compulsion for the CPS to provide an IMR. Where requests are made to provide an IMR, the Chief Crown Prosecutor or Deputy Chief Crown Prosecutor should inform the Chief Operating Officer so that advice and support can be given in undertaking and managing the IMR.

Any IMR provided by the CPS and other relevant agencies will be incorporated in the final Overview Report.

As part of this process, it is therefore important that that those conducting IMRs on behalf of the CPS should not have been directly involved with the case and should not have been the immediate line manager of any staff involved in the IMR.

The Chief Operating Officer will decide with the Chief Crown Prosecutor who should undertake the IMR. This is likely to be a senior member of staff from another CPS Area but it will depend on the circumstances of the case and the Area's involvement. The senior person conducting the IMR should have a clear understanding of the Terms of Reference including requirements such as ownership of the IMR, quality assurance processes and agreeing the final IMR report before the process of review begins.

The Chief Crown Prosecutor will be considered as having commissioned the IMR and will be responsible usually for quality assuring the IMR and ensuring it is delivered on time and agreed as appropriate.

Conducting a IMR

The senior person undertaking the IMR for the CPS should consider the following when compiling an IMR:

  • an accurate chronology of involvement with the victim or defendant in any relevant case is given;
  • all relevant documents including relevant policies and procedures at the time if appropriate should be examined;
  • conduct interviews with the relevant staff involved in the case. A written record of such interviews should be made and should be shared with the relevant interviewee. The interviewee should be assured that the interview forms part of the SCR and that the SCR's purpose is not to apportion blame to an individual but to learn lessons for future practice;
  • names of all staff involved in a case must be anonymised at all stages and not disclosed under any circumstances and Areas are advised to state job title of the staff only. Where the author is unable to interview a member of staff, the reason for this should be included;
  • whether action was taken in respect of decisions made including actions not taken due to shortfall in resources should be taken into account;
  • Areas should advise the Chief Operating Officer of progress on the IMR and ensure the final draft is cleared accordingly; and
  • As it is possible that the IMR will include recommendations about future CPS actions and/or commitments on behalf of the CPS, it is essential that any proposed actions and commitments made on behalf of the CPS must be cleared with the Director and relevant HQ Directorates.

The IMR report must be quality assured by a nominated senior person in the organisation who has commissioned the report and this will usually be the relevant Chief Crown Prosecutor. This senior manager will be responsible for ensuring that any recommendations from both the IMR and, where appropriate, the Overview Report are acted upon appropriately. If necessary, this will be in consultation and agreement with the relevant HQ Directorates.

The IMR should be signed and dated by the IMR author and counter-signed and dated by the nominated senior manager. Areas may wish to use the draft template of an IMR.

Information given by the CPS will be scrutinised and included in the Overview Report which will be published.

IMR Recommendations

On completion of each IMR report, there should be a process of feedback and debriefing for the staff involved in the review, in advance of completion of the Overview Report. There should also be a follow-up feedback session with the relevant staff members once the Overview Report has been completed and prior to its publication. The management of these sessions are usually the responsibility of the relevant Chief Crown Prosecutor.

IMR recommendations for action contained in the report will be considered by the SCR Panel for inclusion in the Overview Report and Action Plan. Recommendations for change can be made, but the Review Panel should seek the agreement at senior level from each of the participating organisations including the CPS in order to check that they are satisfied that their information has been fully and fairly represented. CPS Areas should ensure there is effective communication with the Review Panel and ensure information submitted is accurate.

CPS Areas should note that the Chair may come to a conclusion (drawn from the information supplied in the IMR and other information) which we may not agree upon. Areas should try to bring this to the Chair's attention and see if there is a way forward to resolve the differences. If the issue is not resolved, Areas should request that it should record our view within the Overview Report.

Areas should note that that IMRs are not mandated as part of a SCR and different approaches could be taken. This allows flexibility for local areas to respond to suit their particular circumstances, such, as multi-agency discussions used rather than an analysis of separate written accounts from the different organisations involved. However, LSCBs are able to commission IMRs if they think this is necessary and if it fits with their chosen methodology.

If an LSCB wants the CPS to participate in a review, then they will need to agree locally how this should happen. Whether or not this will mean being invited to attend a number of meetings will depend on the nature of the case, and the level of involvement which CPS has had, but the Review Panel still has the option of asking for written reports if that is more appropriate. Areas should liaise with the Review Panel and agree the method of participation which is appropriate and meets our needs.

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Timescale for completion

The Review Panel is responsible for drawing up their terms of reference and appointing an Independent Chair. The Chair is responsible for managing and co-ordinating the review process and for producing the final Overview Report. The report will normally be produced six months from the date proceedings commenced, unless an alternative time scale has been agreed. The LSCB should aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related criminal proceedings), every effort should be made, while the SCR is in progress, to: (i) capture points from the case about improvements needed; and (ii) take corrective action.

Publication of report

All reviews of cases meeting the SCR criteria should result in a report, which is published and readily accessible on the LSCB's website for a minimum of 12 months. Thereafter the report should be made available on request. Publication is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs.

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Disclosure of Material

Whilst recognising the public interest in the proper conduct of the SCR, prosecutors should be aware about the timeliness of the collection of information by the Review Panel.

During the process of a SCR, material will be generated (e.g. minutes of meetings) and gathered (e.g. IMRs from contributing agencies and notes of interviews). Reasonable enquiries must be carried out by the police to establish what material exists, and whether it may be relevant to the criminal investigation/criminal prosecution. If material relevant to the criminal prosecution exists, the police must alert the CPS to its existence.

Relevant material should be put on to a disclosure schedule in the normal way and reviewed by the prosecutor to assess whether or not the material is disclosable with respect to the disclosure test.

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Serious Case Reviews: vulnerable adults

SCRs are sometimes used in cases involving vulnerable adults and will follow a similar approach to that used for child SCRs. Such reviews are not on a statutory basis. 'Safeguarding Adults' was published by the Association of Directors for Social Services (ADASS) and provides guidance on Vulnerable Adult Serious Case Reviews. This document states that, as a good practice, Safeguarding Adults Boards should have in place a (SCR protocol. A SCR should be undertaken in circumstances where an adult experiencing abuse or neglect dies, or when there has been a serious incident, or in circumstances involving the abuse or neglect of one or more adults.

The purpose of a vulnerable adult SCR is to:

  • establish whether there are lessons to be learnt from the circumstances of the case and about the way in which local professionals and agencies work together to safeguard vulnerable adults;
  • review the effectiveness of procedures;
  • inform and improve local inter-agency practice;
  • improve practice by acting on learning (developing best practice);
  • prepare or commission an overview report which brings together and analyses the findings of the various reports from agencies in order; and
  • make recommendations for future action.

Areas should note that if a request is made for CPS participation in a SCR for vulnerable adults, the same process and principles outlined in SCR for children equally apply to SCR for vulnerable adults. Areas should treat SCR for vulnerable adults as the same as children and ensure that sufficient information is obtained so that an assessment can be made whether to participate or not.

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