The LSCP Review Advisory Group (RAG) is responsible for identifying learning in relation to the most serious cases, including Serious Child Safeguarding Incidents (SCSIs), identifying good practice and areas of learning and improvement.
The fundamental purpose of reviewing incidents where children who have either died because of abuse or neglect, or where children have been seriously harmed, is to learn from those cases to help make improvements to systems that protect children and to prevent other children from being harmed.
A central role is to seek assurance related to actions taken following local learning activities, Rapid Reviews, Local Child Safeguarding Practice Reviews (CSPRs) or National Child Safeguarding Practice Reviews. The RAG requests support from other LSCP subgroups to disseminate learning, undertake quality assurance work to measure impact and to seek assurance that partner agencies use their own internal structures to implement recommendations.
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 a local level with the safeguarding partners.
Leeds has a robust review process in place which ensures that cases are considered in a timely manner in line with the requirements of the guidance, considers the views of the three safeguarding strategic partners and is overseen by a clear governance process, which is published on the website.
Notifications of SCSIs
The legislative framework of the Children Act 2004, places a duty on local authorities in England, to notify the Child Safeguarding Practice Review Panel (the ‘Panel’), of incidences of death or serious harm where it is known or suspected that a child has been abused or neglected. This includes those children that maybe temporarily outside the local authority’s area in which they usually reside.
The revised Working Together to Safeguard Children 2023 states that the local authority performs this duty on behalf of the safeguarding partners.
The local authority should notify the Panel of any incident that meets the above criteria via the Child Safeguarding Online Notification System. It should do so within five working days of becoming aware it has occurred.
In Leeds the LSCP has in place a process for discussing and agreeing those incidents which may meet the criteria for making a notification (the SCSI Notification Process). This process has oversight from its Executive and legal advice is provided, and in this reporting period all decisions have been unanimously agreed.
The local authority has a separate duty to notify the DfE and Ofsted when a looked after child dies, up to and including the age of 24 (in accordance with its leaving care duties). There is no automatic requirement for a local child safeguarding practice review, unless the criteria are met. However local partners may convene a local review if they think learning may be gained.
In Leeds the Review Process has been reviewed and updated in line with the requirements of Working Together 2023.
The LSCP RAG collectively considers whether an incident meets the criteria for a SCSI notification, with the relevant partner agencies providing information and professional opinions to support the decision making. Following the notification of a SCSI by the local authority to the National Safeguarding Panel the LSCP through the LSCP RAG will promptly undertake a Rapid Review.
Cases for consideration are raised to the RAG via partner agencies using the SCSI notification and discussion form.
When an agency other than the local authority becomes aware of an incident that appears to meet the criteria for notification, the relevant partners discuss this with their agency’s safeguarding lead (or RAG member) and if appropriate refers this to the LSCP RAG for a discussion in relation to a potential notification.
In 2023-24 the RAG considered four cases for notifications where the decision was made that they did not meet the criteria for notification. In these cases, feedback was given to the partner agency who raised the concern and the rationale for the decision made.
Rapid Reviews
A Rapid Review is a multi-agency process which considers the circumstances of a SCSI. The purpose of the Rapid Review is to identify and act upon immediate learning and consider if there is additional learning which could be identified through a wider Child Safeguarding Practice Review (CSPR).
The Rapid Review enables 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
- Identify immediate learning and consider the potential for identifying improvements to safeguard and promote the welfare of children
- Decide what steps they should take next, including whether to undertake a local Child Safeguarding Practice Review (CSPR).
Once the Rapid Review responses have been received, RAG members meet, alongside the Rapid Review individual report authors, to consider the information, key learning points and areas for further consideration. This allows authors to share their information in a responsive way and ensure that the process is not remote.
RAG members then meet separately to consider if the criteria to undertake a review is met.
Minutes of all meetings are produced alongside the Rapid Review form, capturing the rationale for any recommendations made and shared with the LSCP Executive, who make the final decision, prior to submission to the Panel.
In 2023-24, in Leeds there were four Rapid Review processes completed and sent to the Panel, which related to five children.
The first case followed the death of a child. A Rapid Review was undertaken with a recommendation not to proceed with a CSPR, the Panel agreed with this decision.
The second, was originally discussed in relation to the abuse of three children, and the decision made for a single agency review - this was agreed by Panel. However, they advised if any further children were identified through the police investigation, then a CSPR ought to be considered.
Two further children were identified to be linked, and a subsequent Rapid Review was completed which recommended a CSPR.
A fourth Rapid Review related to the death of a baby and recommended that a CSPR be completed.
CSPRs
In 2023-24, one CSPR was completed; this was considered to be an exceptional case with reasons not to publish, including the potential adverse impact that publication could have on the subjects; this decision was supported by the Panel.
There are three ongoing CSPRs which have progressed this year and are at varying points of completion. Two further new CSPRs were agreed this year, one being a joint review with a neighbouring authority.
Progress with all the CSPRs in Leeds is overseen by the RAG and regular reports received by the Executive.
Some CSPRs have been delayed due to the availability of suitable authors, with local and wider partnerships expressing similar difficulties.