Healthcare Business: Are Serious Case Reviews fit for purpose?

In the last few weeks, the Serious Case Review detailing the tragic death of Daniel Pelka was published which highlights that, whilst the various agencies involved with Daniel could not have predicted his death, there were too many missed opportunities for them to take action.  This is the theme of many Serious Case Reviews of the last few years and questions have been asked about why the same mistakes keep being made?

A serious case review (SCR) must be held when:

  • abuse or neglect of a child is known or suspected; and
  • 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 agencies involved with the child have worked together to safeguard the child.

In May 2011 the Munro Review was published stating, amongst other things, that SCR’s should have a stronger focus on understanding why things happen – not just what did happen.  Speaking to the BBC, in respect of the Daniel Pelka SCR, Professor Eileen Munro stated the report was “very frustrating” and it was “written totally with hindsight saying now that we know what was happening to Daniel they should have noticed.”

The purpose of a serious case review is to enable lessons to be learned about the way agencies worked individually and together in respect of the child concerned.  It is not to attribute blame or to say how a child died.  It is of course very difficult not to attribute blame to agencies who failed to do something which could have protected a child from harm.

Whilst a SCR is not in itself a criminal or civil process, there may be criminal or civil processes that flow from such circumstances warranting a SCR and therefore agencies involved understandably want to protect their position.  Where a child has died in care it is that establishment that is likely to be the main focus.  What impact will findings of failings by agencies such as the local authority or health authority or police have on these authorities?  Very little.  Some adverse media interest perhaps but essentially as public authorities they will continue their roles with little influence.  What sort of impact will findings of failings have on a children’s home?  Well quite a lot.  Will placing authorities stand by a home where a child died?  What sort of reputational impact will a published SCR have on a home?

All SCR’s initiated on or after 10 June 2010 must have the Overview Report (the body of the report which contains all the details of the case) and Executive Summary published unless there are compelling reasons relating to the welfare of any children directly concerned in the case for this not to happen.    Previously only the Executive Summary was produced, however, in a bid to be more open and transparent the Overview Report will also be published.  What about children not directly involved?  What about children living in an establishment where a child died?  Should they not be protected from intruding press members?

The Overview Report and Executive Summary must be sufficiently redacted and anonymised however, it does not take much to identify the child or establishment concerned.  Put a few key words into an internet search engine and you’re likely to find a news report detailing the original death.  However, there has been at least one SCR this year where even the Local Safeguarding Children’s Board (“LSCB”) was not identified.  Surely total anonymisation is the way forward?

SCRs are supposed to be initiated quickly so that lessons can be learned quickly.  However, where there are ongoing investigations, such as police investigations, agencies are asked not to speak to potential witnesses or suspects in case evidence is “tainted” as a result.  However,  undertaking a review based on paperwork alone is unlikely to produce a full picture.  Only through interviews with staff will a complete picture be produced.  Working Together requires parties to learn lessons, however, without a full picture, any lessons will be meaningless and could indeed be incorrect if a thorough review is not undertaken.

The process of an SCR is somewhat absurd.  Each agency that had involvement with the child must produce an Independent Management Review report which reports on the particular areas/issues identified by the LSCB in the SCR’s Terms of Reference. A chronology is also produced where each agency must provide detail of every interaction with the child.

Each agency produces their reports – they don’t get to see the other agency reports or get to challenge what someone else says but the Overview Report Writer then uses these reports to write the Overview Report – the Overview Report Writer does not undertake their own investigation or look at source material – they merely use the reports that have been produced by each agency.  Whilst the SCR process should not be adversarial parties should be given the opportunity to challenge something which they believe to be wrong and matters should not necessarily be taken at face value.

The Overview Report can only be as good as the underlying documents produced.  As noted above the chronology itself must detail every interaction with the child.  This and the IMR can be extremely time consuming.  Individuals who compile these have day jobs too and the pressure to turn around comprehensive documents in a small time frame could result in flawed documents being produced.

In the rush to learn lessons I have seen SCR’s initiated where an assumption of the cause of death has formed part of the Terms of Reference before there has been a coroner’s inquest – the only person who can conclude the cause of death.  For example, in a case I was involved in there was a particular assumption of how the child had died.  An Overview Report running to 150 pages discussed recommendations based on the assumed cause of death but when the coroner did make his findings the verdict was very different.  The Overview Report conclusions were wrong.  This was a pre-2010 SCR but if it had been published this could have caused a number of problems for the provider.

LSCBs now have access to a National Panel of Independent Experts which was announced in Working Together to Safeguard Children in March 2013.  This panel will provide Local Safeguarding Children Boards with access to expert advice about conducting and publishing SCRs.  It will be interesting to see what impact this Panel will have, if any, on the SCR process.

The death of any child is incredibly sad and whilst agencies should co-operate in order to learn lessons, what is incredibly important for any provider who finds itself partaking in a SCR is to ensure that the documentation submitted as part of the process contains everything it wants to say.  If it’s not in your paperwork, it won’t be reflected in the Overview Report or Executive Summary.  All too often, agencies focus on the negatives and their failings and whilst it is important to recognise these in order to learn from them, it is also important to recognise good work undertaken.  It’s unlikely that you will have the opportunity to comment further on an Overview Report and in turn the Executive Summary so the key is full documentation from the word go.  Providers should not succumb to pressurised deadlines at the expense of producing less than complete documentation which will reflect badly on them in the long term.

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