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Learning Reviews

   

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

Sometimes a child suffers a serious injury or death as a result of child abuse or neglect. Understanding not only what happened but also why things happened as they did can help to improve our response in the future. 

Working Together, Chapter 4, Page 82

A Serious Incident is one where:

  • 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.

The Local Authority must notify any event that meets the above criteria to the National Panel within 5 working days from being aware of the incident. The Partnership Agencies must then consider whether the case meets the criteria for a Local Child Safeguarding Practice Review (LCSPR).  
   

The purpose of a Local Child Safeguarding Practice Review (LCSPR)

The purpose is for agencies and individuals to identify improvements to safeguard and promote the welfare of children at both local and national levels and learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children.

Reviews are not conducted to hold individuals, organisations or agencies to account, since other processes have this function (employment law, disciplinary procedures, professional regulation and in exceptional cases, criminal proceedings).

           

Criteria

The criteria described in Working Together to Safeguard Children 2018 (Chapter 4, Page 85) includes 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
  • recurrent themes in the safeguarding and promotion of the welfare of children
  • 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

Regard should be given to the following circumstances:

  • where there is cause for concern about the actions of a single agency
  • where there has been no agency involvement and this gives the safeguarding partners cause for concern
  • where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around
  • where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings

The Learning Inquiry Group (LIG)

The LIG oversees Child Safeguarding Practice Reviews. Membership consists of senior representatives within partnership agencies. These include:
  • Children’s Social Care Services
  • Police
  • Health commissioners and providers
  • Education
  • Probation
  • Youth Justice Service

Referrals to the Learning Inquiry Group (LIG)

  • Any partner / relevant agency can refer a case to the LIG
  • All professionals referring cases should initially  discuss the case with their agency representative at the LIG for approval
  • Referral forms should be submitted to the Partnership Team at SCP@iow.gov.uk and must include:
    • Names, dates of birth and address(es) of adults involved in the child's care
    • Any known alias or alternative spellings of names
    • other agencies working with the family
    • analysis of the practie undertaken in the case, highlighting strengths and areas of challenge
The Case Referral Form can be found here and the referral flowchart can be found here .
 

Referral responses

Once a referral has been received and discussed with the LIG Chair, a decision will be made as to which of the following three will occurr:
 

Rapid Review

  • Only if a Serious Incident Notification is completed
  • Completed within 15 days of an incident
  • Practitioners complete Referral Response Forms
  • LIG complete a rapid review form which is sent to the National Panel.
Scoping
  • Completed at the next scheduled LIG meeting
  • Practitioners complete Referral Response forms.
  • LIG members discuss the response forms and decide how best to ensure learning is identified and disseminated

Safeguarding Leads

  • The LIG Chair, in consultation with LIG members, may decide to send the case to the Safeguarding Leads meeting for a fuller discussion to enable learning to be identified, acted upon, and disseminated. Where they feel the case does not meet the criteria for a LCSPR.

The aim of the Rapid Review or Scoping Process is to enable safeguarding partners to:

  • gather the facts about the case;
  • 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 an LCSPR
   

Outcomes of Rapid Review/Scoping

Where potential for further learning from a case is identified, the LIG may commission a proportionate Local Child Safeguarding Practice Review (LCSPR). The following is the agreed menu of Isle of Wight approaches. All LSCPRs are classed as either Local or National Reviews and the expectation is that they are published. Further details on the methodologies to be can be found hereThis includes the process and who leads the review of the case.

  • Option 1 - Single agency Review
  • Option 2 - LCSPR (Partnership workshop)
  • Option 3 - LCSPR (Local Learning Review)
  • Option 4 - National Child Safeguarding Practice Review
   

LCSPR Publication

After the completion of a Review, the report will be published on the IOWSCP website. The report will include learning from the review and recommendations for action.

  • A brief overview of what happened and the key circumstances, background and context of the case.
  • An analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report
  • A critique of how agencies worked together and any shortcomings in this
  • A summary of whether any shortcomings identified are features of practice in general
  • A description of what would need to be done differently to prevent harm occurring to a child in similar circumstances
  • Any recommendations should be clear on what is required of relevant agencies and others collectively and individually, and by when, and focussed on improving outcomes for children
   

IOW LCSPR Reports:

IOW Serious Case Reviews:

    

Further information

Further information and guidance in relation to LCSPRs can be found in the statutory guidance Working Together 2018.