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7.1.3 Greater Manchester Serious Case Review Systems Approach


The North West Learning and Improvement Framework

This guidance provides a framework which Greater Manchester LSCB’s may choose to use to carry out Serious Case Reviews. It is designed to be applied flexibly while still providing an element of consistency for our region.


This chapter was updated in June 2016. Section1, Principles, was given a general refresh in line with Working Together to Safeguard Children 2015.


1. Principles
2. Key Elements for a Systematic Approach
  2.1 Serious Case Review (SCR) Threshold Meeting
  2.2 Review Panel
  2.3 Initial Review Panel Meeting
  2.4 Single Agency Analysis Reports
  2.5 Engaging Family Members
  2.6 Learning Event
  2.7 Further Review Panel Meetings
  2.8 SCR Final Report
  2.9 LSCB Response to Recommendations / Practice Challenges
  Appendix 1: Suggested Single Agency Analysis Report Content

1. Principles

Working Together 2015 does not provide a prescriptive approach as to how Serious Case Reviews should be conducted; rather it states that any learning model can be used as long as the process is:

  • Carried out in a manner that is proportionate to the case, according to the scale and level of complexity of the issues being examined;
  • Led by individuals who are independent of the case under review and of the local organisations whose actions are being reviewed;
  • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process;
  • Final reports of SCRs must be published, including the LSCB's response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections;
  • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice;
  • Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children.

In terms of implementing a Systems Approach the following principles should be satisfied:

  • Understanding not only the action taken or not taken at significant points but appreciating why practitioners and managers made these decisions;
  • Distinguishing between skills and knowledge deficits among individual practitioners that impact on practice from the strategic and systematic constraints under which practitioners may be operating and the impact of this;
  • Taking into equal account the experience of all contributors to the multi-agency system;
  • Identifying and understanding to what extent the individual case reflects practice in general in the area.

SCRs and other case reviews should be conducted in a way which:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
  • Is transparent about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

2. Key Elements for a Systematic Approach

2.1 Serious Case Review (SCR) Threshold Meeting

All Greater Manchester LSCB’s will have processes in place to identify those incidents which meet the criteria for a SCR. Where the recommendation has been made that a case reaches the threshold for an SCR the following will need to be agreed to support the identification and establishment of the Review Panel:

  • Identification of the Review Panel, Lead Reviewer and timetable for the review process;
  • Agreeing the time period for the review – it is recommended that a systemic approach focuses on a timescale of no more than twelve months prior to the incident(1);
  • Developing a Family Association Network / Genogram;
  • Identifying the agencies who need to contribute to the review and any other sources of  information;
  • Identify any other processes that may impact on the review or the review process;
  • Identifying an independent Panel Chair – this could be commissioned or drawn from a LSCB agency not involved with the child or their family;
  • Tasking key agencies with preparing their agency timeline and a brief analysis of the agency involvement – this should take account  of the context in which practitioners are working.

Satisfying the points above will provide an initial scope for the review. This will be subject to change as the review process progresses and additional information and knowledge is identified.

(1) In exceptional circumstances this could be increased to twenty four months – where there is significant historic information this should be summarised to key points with an emphasis on what was known, who knew, how the it influenced and contributed to assessment and decision making.

2.2 Review Panel

The Review Panel is required to manage the process of the SCR and plays a key role in ensuring that learning is gained from the process. Members of the Panel should be representative of the agencies and services involved with the child and their family but should not have had any direct involvement. The review Panel should be multi-agency in nature and agencies should ensure commitment and consistency in membership of the panel.

The Lead Reviewer should be someone with the skills, knowledge and experience of working in a multi-agency arena and in producing concise, analytical reports. The Lead Reviewer should be independent of agencies involved with the child and their family; the Lead Reviewer could potentially be:

  • An LSCB member with no links to the child, their family or the services involved;
  • LSCB member from another area;
  • An independent person commissioned by the LSCB to deliver the review.

Consideration should be given as to whether a co-reviewer should be appointed and this will be dependent on the complexity of the situation. The same criteria would apply to appointing the co-reviewer.

The LSCB should be satisfied that those appointed to the post of ‘Reviewer’ have been recruited in accordance with the LSCB’s safe recruitment processes. In some cases criminal proceedings may follow the death or serious injury of a child. The Review Panel should discuss with the relevant criminal justice agencies such as the police and the CPS, at an early stage, as to how the review process should take account of such proceedings when planning the elements of the review. The same consideration should be given to any Coronial processes that could take place.

2.3 Initial Review Panel Meeting

This meeting will be responsible for:

  • Ensuring relevant national bodies including Ofsted, Department for Education and National SCR Panel have been advised an SCR has been commissioned;
  • Agreeing the merged timeline, reviewing the single agency analysis and confirming the key events to be considered from the timeline;
  • Agreeing the Family Association Network / Genogram, identifying the family members to be involved in the review process - being clear as to why they are being invited  to contribute and discussion about  how this will be facilitated;
  • Evaluating the Single Agency analysis reports if already submitted or setting out the terms of reference and requests for such reports;
  • Confirming any other processes that run parallel to the SCR and considering any opportunities or risks presented by these;
  • Confirming any additional information sources and agreeing how these will contribute to the review process; including involvement from LSCB’s in other areas;
  • Setting out the timetable for the review to ensure it is completed in a timely manner  – this will include scheduling for the Learning Event, meeting with family members, dates for future Review Panel Meetings, presenting the report to the LSCB and building in time for any slippage or unforeseen circumstances;
  • Using the available information to plan the framework for the multi-agency practitioner learning event, this will include:
    • Managing the logistics for the event – venue, date, times, admin support, how many learning events etc;
    • Identifying the practitioners who need to attend and ensuring they are supported to engage in the process; understanding the challenges they face in attending such an event with their peers and senior managers;
    • Ensuring any impact for practitioners during and following the Learning Event are identified,  risks managed, contingencies in place with relevant support in place on the day;
    • Agreeing the format and agenda for the Learning Event;
    • Creating a Learning Event that encourages open and honest discussion, debate and challenge while avoiding defensive practice. 

2.4 Single Agency Analysis Reports

The SAARs should be specified for each review. The specification is flexible so that each review will receive the information it requires, proportionate to the concerns raised by the case.

A sample format for SAARs is provided at Appendix 1:Suggested Single Agency Analysis Report Content.

It is intended that the SAAR should be a dynamic document subject to revised iterations and, in a timely manner, should incorporate a single agency action plan.

The SAAR should also be a tool for use at the Learning Event. Agency representatives at the event should liaise with the SAAR author to ensure the learning from the event is incorporated in the SAAR.

This approach should reflect the learning that is achieved by each agency in the light of the considerations of the SCR process.

2.5 Engaging Family Members

Family members can offer a unique perspective into how the delivery of services and involvement of agencies were viewed and responded to. It is essential that the Review Panel have opportunities to listen to family experiences and perspectives and that these contribute meaningfully to the final report. Family members can include:

  • The child;
  • Siblings;
  • Parents;
  • Carers;
  • Grandparents;
  • Other significant family members identified from the Family Association Network / Genogram.

As a minimum, family members should:

  • Be notified of the review process, what that means for them and how they can access support – including impact of media coverage;
  • Agree the level and frequency of contact with family members to ensure they are kept informed;
  • Supported to contribute to the review process – either in writing, by meeting with the review panel, sharing views via a third party or by other means identified by the Review Panel;
  • Included in feedback about the learning identified by the Review Panel;
  • Informed and prepared for the publication of the report in a timely manner – again including the likelihood of media interest;
  • Provided with a read only copy of the report which family members can review and comment on prior to publication but not retain; where possible any relevant comments should be incorporated into the final version –  A ‘hard’ copy of the report should not be provided until the report is in the public domain.

2.6 Learning Event

The Learning Event should be facilitated by the Lead Reviewer, supported by the Review Panel. The Learning Event can be a single event or held over a series of sessions dependent on complexity and the identified learning. The aim of the Learning Event is to:

  • Share the key themes and significant events identified by the Review Panel;
  • Seek the views and experiences of practitioners as to the factors which contributed and influenced their assessment, analysis, action and decision making – this should include reflection on personal and organisational factors;
  • Provide an opportunity for practitioners to reflect identifying the strengths and areas for development – including consideration of should anything have been done differently;  in what ways and why;
  • Identify single and multi-agency  practice learning points which will contribute to the final report;
  • Agree how practitioners will receive feedback and follow-up on how their contribution has influenced the report findings and challenges.

It is expected that all members of the Review Panel and attending practitioners prioritise attendance and are supported to attend by their organisation.

It will be the responsibility of the Lead Reviewer, with relevant identified support from the Review Panel to draw together a summary of the issues, learning and challenges. These should be presented for discussion to the next meeting.

2.7 Further Review Panel Meetings

It is likely that as a minimum two further Review Panel Meetings will be required:

  1. To review the outcomes from the Learning Event;
  2. To comment on the SCR Draft Report.

Where additional meetings are required these should be planned within the existing timetable to avoid drift and delay in completing the review.

2.8 SCR Final Report

This document brings together the learning and themes identified from the review and will analyse and comment on the effectiveness of practice and the systems used to safeguard and promote the welfare of the child.

The Lead Reviewer has responsibility for collating the report and the report should:

  • Provide a summary of the circumstances that led to the review;
  • Briefly outline the review process and methodology, including how the views and participation of key stakeholders as achieved;
  • Be written in a succinct and focused manner with the emphasis on recognising and sustaining good practice as well as identifying how and where practice can be improved in the future;
  • Identify action that agencies or services have already undertaken in response to learning;
  • Form a conclusion as to the effectiveness of local practice to safeguard and promote the welfare of children - this includes conclusions that indicate systems have not failed and have been effective but still resulted in harm to a child.

The SCR Final Report should firstly be presented to the Review Panel. This provides an opportunity for the Lead Reviewers and Panel Members to quality assure the document, reference the identified learning to the findings from contacts with practitioners and family members and to ensure an opportunity for the findings to be challenged where necessary. This meeting also provides the chance for Practice Challenges or Recommendations to be formulated and incorporated into the final SCR Report. 

Once agreed the report should be presented to the LSCB by the Lead Reviewer, supported by the Review Panel Chair. 

2.9 LSCB Response to Recommendations / Practice Challenges

It will be the responsibility of the LSCB and its Independent Chair to identify and agree how practice challenges or recommendations from the SCR Report will be responded to and what action is needed by individual agencies or from a multi-agency perspective. 

A clear action plan should be developed by the LSCB with a focus on improving outcomes for children. The following should be included in the Action Plan as standard:

  • A timeline for publication of the report should be developed and where possible a date identified;
  • Action is taken by the LSCB to share the findings of the report with the practitioners who contributed to the Learning Event and with family members;
  • The LSCB identifies how it will share the lessons learned and practice impact with the wilder childrens workforce in their area.

Once the SCR Report and Action Plan have been agreed the report should be endorsed and signed off by the LSCB and copies submitted to Ofsted, Department for Education and the National SCR panel.

The plan should be regularly reviewed and its impact evaluated using existing LSCB processes.

Appendix 1: Suggested Single Agency Analysis Report Content


This should include the circumstances of the agency’s involvement with the child / family including reason for referral.

The Facts

This should include:

  • The family background and circumstance;
  • An outline chronology of significant events in the agency’s involvement with the child / family.


This section should critically assess the key circumstances of the agency’s engagement with the child/family. For example:

  • Were the responses appropriate?
  • Were key decisions justifiable?
  • Was the relevant information sought or considered?
  • Were there early, effective and appropriate interventions?
  • Were the family and child's circumstances sufficiently assessed?

Key Issues

Following on from the analysis and depending on the circumstances of the case, the review should clearly identify the key areas that impacted on the child and agency responses and then explore these further to understand how they came about. This section should assist in understanding the 'why' of what happened. It would be helpful to explore key areas within a framework of cause and effect factors – for example, resourcing, organisational culture, training, policies etc.

Learning Points

This section should highlight the key learning points from the review – again the focus here should not be on 'what happened', but the reasons for why it happened as it will be these areas that agencies can actively take forward and address. This section should also address strengths and good practice identified as well as the learning that has taken place since the case, any changes in practice and policy that have been implemented and the outcome of changes.


These should be SMART: Specific, Measurable, Achievable, Realistic, Timed.

Action Plan

The Action plan should reflect the required activity to achieve the recommendations and be owned by the whole agency. Mechanisms to review the outcomes and impacts of such actions should be agreed and formally built into the improvement programme.