SGSOP14 Child SG Practice Review SAR and DHR SOP V6 by Provide Community

Standard Operating Procedure for Child Safeguarding Practice Review, Safeguarding Adult Review and Domestic Homicide Review

Version: V6

Ratified by: QPLT

Date ratified: 27/09/2022

Job Title of author: Named Nurse Safeguarding Adults and Children

Reviewed by Committee or Expert Group Strategic Safeguarding Group

1. Introduction

Under the legislation outlined below Provide Community Group could be required to contribute to Reviews where there has been the death or serious harm involving a family under our care of any age and in various circumstances which fulfil the criteria for a Review. This Standard Operating Procedure sets out how Provide Community Group staff will proceed following requests for reports critically analysing our involvement in these cases. For Serious Adult Reviews (SARs) the referral process has also been included.

In some circumstances there will be an overlap with statutory requirements to undertake reviews and parallel processes will be considered with joint commissioning from the relevant Board. In all cases any criminal proceedings take precedence.

Child Safeguarding Practice Reviews (CSPR)

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. Understanding the impact that the actions of different organisations and agencies had on the child’s life, and on the lives of his or her family, and whether or not different approaches or actions may have resulted in a different outcome, is essential to improve our collective knowledge. It is in this way that we can make good judgments about what might need to change at a local or national level.

The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policy- makers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.

Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage. Employers should consider whether any disciplinary action should be taken against practitioners whose conduct and/or practice falls below acceptable standards and should refer to their regulatory body as appropriate. (Working Together to Safeguard Children, 2018)

Under the legislation outlined below Provide Community Group could be required to contribute to Reviews where there has been the death or serious harm involving a family under our care of any age and in various circumstances which fulfil the criteria for a Review. This Standard Operating procedure sets out how Provide Community Group staff will proceed following requests for reports critically analysing our involvement in these cases. In some circumstances there will be an overlap with statutory requirements to undertake reviews and parallel processes will be considered with joint commissioning from the relevant Board. In all cases any criminal proceedings take precedence.

All Provide Community Group services are required to fulfil their legal duty under Section 11 of the Children Act 2004 and statutory responsibilities set out in Working Together to Safeguard Children (HM Government, 2018). Therefore, safeguarding and promoting the welfare of children must be an integral part of the care offered to all children and their families by all health care professionals working within Provide Community Group.

Failure to ensure a child’s access to health care falls within the category of Neglect and Provide Community Group takes a proactive approach in identifying children and young people who are prevented from accessing appropriate medical care and treatment. This may be care offered to children, young people, families or adults who are parents or carers.

A Child Safeguarding Practice Review is initiated when abuse or neglect of a child is known or suspected and either the child has died or 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.

There is a duty on Local Authorities to notify the National Child Safeguarding Practice Review Panel if:

• The child dies or is seriously harmed in the local authority’s area; or

• While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

They must also notify the Secretary of State for Education and Ofsted where a Looked After Child has died, whether or not abuse or neglect is known or suspected.

Safeguarding Adult Reviews (SAR)

Section 44 of The Care Act 2014 introduced Safeguarding Adult Reviews (SAR) and made Safeguarding Adults Boards responsible for initiating the SAR:

• When an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.

• Where an adult is still alive but has experienced serious neglect or abuse, and there is concern that partner agencies could have worked more effectively to protect them.

• In other situations where it feels there is a value in doing so, for example to prevent or reduce abuse or neglect or explore practice

SARs should seek to determine what the relevant agencies and individuals involved in a case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm from occurring again. Its purpose is not to hold any individual or organisation to account.

Domestic Homicide Reviews (DHR)

Domestic Homicide Reviews (DHR) were established on a statutory basis under section 9 of the Domestic Violence, Crime and Victims Act 2004 which came into force on 13 April 2011. DHRs review the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were in an intimate personal relationship, or by a member of the same household. Where a victim took their own life (suicide) and the circumstances give rise to concern, such as it emerging that there was coercive controlling behaviour in the relationship, a DHR should also be carried out. Such reviews are carried out in local areas by Community Safety Partnerships (CSP), or local Domestic Abuse Boards. The reviews are undertaken with a view to identifying the lessons to be learnt from the death, particularly regarding the way in which professionals and organisations work together to safeguard victims. (Home Office 2016).

A Domestic Homicide Review looks at the circumstances in which the death of a person aged 16 or over has or appears to have resulted from violence, abuse or neglect by a person to whom they were related or have been in an intimate relationship with or a member of the same household, which looks at the lessons to be learnt from the death. Overall responsibility for establishing the review rests with the local Community Safety Partnership (CSP) or Domestic Abuse Board.

When Victims are aged 16-18 there are separate requirements in statutory guidance for both a DHR and CSPR. These need to be managed in parallel and the LSCB and CSP will decide on the most effective way to jointly commission or coordinate the dual process to reduce duplication of work for the organisations involved.

There also may be occasions where a joint SAR and DHR is commissioned and the overview report author will complete a combined report with both LSCB and DAB/CSP agreeing the terms of reference. When running reviews in parallel it will be important at the outset to establish all the relevant areas that need to be addressed, to reduce potential for duplication for families and staff. Any review will need to take account of a coroners enquiry, and, or, and criminal investigation related to the case, including disclosure issues, to ensure that relevant information can be shared without incurring significant delay in the review process.

2. Purpose

The aim of this Standard Operating Procedure is to provide staff with a reference guide so that they may fulfil their statutory duties to safeguard and protect victims of abuse and neglect, and ensure that incidents are investigated and lessons learnt accordingly.

3. Scope

This Standard Operating Procedure (SOP) applies to all staff employed within Provide Community Group and includes:

• Temporary, voluntary, contracted or self-employed staff working on behalf of Provide Community Group

• Bank /agency staff working on behalf of Provide Community Group

The above will be referred to as ‘all staff’ in the SOP

The Children Act 1989/2004 states a child is anyone who has not yet reached their 18th birthday. ‘Children’ therefore in most documentation means ‘children and young people’ throughout.

4. Duties within the organisation

All staff have a duty to safeguard children, young people and adults at risk, by recognising abuse and referring onwards as required in line with current legislation, statutory guidance and Provide Community Group suite of Safeguarding Policies.

On receipt of notification of a CSPR, SAR or DHR from the Commissioning Board the Group Chief Executive Officer appoints a reviewing officer/author who is normally a member of the Provide Safeguarding team, or they may commission an independent author. They in turn are responsible for completing the Individual Management Review (IMR) on behalf of Provide Community Group.

It will be expected that initial scoping information for a Review will be returned to the relevant Commissioning Board Review Panel within the requested timescales. A decision will be made by the Panel within one month whether to proceed or not with the review, and the process should be completed within six months. For all reviews, any criminal investigation takes precedence and therefore there may be a delay in proceeding with the review.

All Provide Community Group Staff have a responsibility to cooperate with all aspects of any review and give information to the reviewing officer in a timely fashion.

Provide Community Group has a duty of care for employees. The emotional welfare of staff involved in CSPR, SAR & DHRs should be considered throughout the process. Referral to appropriate supportive services such as counselling should be offered.

Provide Community Group is required to ensure their reviewing officer is given due time and support to complete the reviews

5. Process/Procedure

CSPR

If the Local Safeguarding Children’s Board decides that an incident referred to them meets the CSPR criteria, they need to complete a rapid review of the case within 15 days. Once completed the LSCB should send a copy of the rapid review to the National Child Safeguarding Practice Review Panel. Along with their decision whether to proceed with the CSPR or if they think the case may be of national importance. Once the local review is determined they should inform the Panel, Ofsted and Department of Education.

If the CSPR criteria are not met, the LSCB may still decide to commission an alternative form of case review under the Learning and Improvement Framework. (Working Together to Safeguard Children, 2018)

See Process map at section 8

SAR

Any agency can make a referral to the LSCB Safeguarding Adults Review Panel (For Essex: use Form SAR1 in Appendix 1). Please discuss with the safeguarding team if you have concerns about an adult and you think it would meet the referral criteria. The safeguarding team will support you to refer the case for consideration by the review panel The Panel is made up of representatives from LSAB partner agencies and must include Social Care, Police and Health (ICB and Providers) and are responsible for deciding if the referral information meets the criteria for a SAR. The independent chair of the LSAB will make the final decision and may request a discretionary SAR.

See Process map at section 9

DHR

Police will notify the Domestic Abuse Board (DAB) or Community Safety Partnership (CSP) when a domestic homicide occurs.

Initial scoping letters will be sent to all agencies in the locality who are required to check their records for any involvement with the family and complete an initial chronology or send a nil return if not known to their service.

Once all agencies have returned the initial scoping documents, the DAB/CSP chair will decide whether this meets the criteria to proceed with a DHR The decision to proceed or not should be communicated to the Home Office, and the victim’s family informed

Police investigations will always take primacy in criminal investigations The Review process should be completed within six months of initiation and therefore Provide Community Group should not wait for the outcome of the review Outcomes from the initial investigation should be acted upon quickly as part of a risk management process. With Complex cases where there are parallel processes identified the Commissioning Board may choose to jointly commission a lead overview writer for the case.

All reviews are published once completed including:

• any actions already taken in response to the review findings

• The impact these actions have had on improving services

• And what more will be done

Published review are anonymised and the family are consulted on a pseudonym that will be used on publication.

See Process map at section 10.

Information Sharing

A Statutory Duty to co-operate between agencies for the purpose of conducting reviews exists within the relevant legislation which provides that local authorities must co-operate and collaborate with each of their relevant partners and those partners must also cooperate with the local authority in order to share relevant information for the review.

Information when requested for a Review should be provided by all relevant agencies involved with the family

Report Overview writers will liaise with families involved in the review throughout the process and especially prior to publication of the final reports.

Purpose of a Child Safeguarding Partnership Review (CSPR), Safeguarding Adult Review (SAR) and Domestic Homicide Review (DHR)

• To establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work individually and together to safeguard victims.

• The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCB will also want to review instances of good practice and consider how these can be shared and embedded. Working Together to Safeguard Children 2018).

• To 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.

• To apply these lessons to service responses including changes to policies and procedures as appropriate and prevent domestic violence and abuse homicide and improve service responses for all domestic violence and abuse victims and their children through improved intra and inter-agency working.

• Highlight good practice

It is, important to note that reviews should not simply examine the conduct of professionals and agencies. Reviews should illuminate the past to make the future safer and it follows therefore that reviews should be professionally curious, find the trail of abuse and identify which agencies had contact with the victim, abuser or family and which agencies were in contact with each other. From this position, appropriate solutions can be recommended to help recognise abuse and either signpost victims to suitable support or design safe interventions

The Review purpose is not to hold any individual or organisation to account. Other processes exist for this purpose, including criminal proceedings, Coroners enquiries, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council and the General Medical Council.

For all reviews

Initial scoping of all agencies within the local area will be completed. The reviewing body with make the request to the Provide Community Group Safeguarding team who requested will check the records to see if the people involved are known. If not known then a nil return should be sent. If the family are known to Provide Community Services then the Safeguarding Team secure the records and complete an initial chronology outlining any involvement with services which is then submitted for consideration by the appropriate panel.

If the decision is made to proceed then the reviewing panel will decide which agencies are required to complete an Internal Management Reviews (IMR). The Provide Community

Group Chief Executive Officer will appoint the IMR author (usually from the Safeguarding Team)

The findings and analysis from the Review will be brought together with other agencies and organisations’ reviews into an ‘Overview Report’. The Overview report is the amalgamation of all agencies IMRs, the health overview report and recommendations.

6. Conducting an IMR

Once the review has been requested and a reviewing officer/author appointed, the electronic records for all relevant family members will be restricted and any paper records secured. The paper records will be copied with the originals held by the Safeguarding team and the photocopy used as a working record.

Those conducting IMRs should not have been directly involved with the family and should not have been the immediate line manager of any staff involved in the IMR as this would be seen as a conflict of interest

The aim of the IMR is to:

• Work within the terms of reference set by the review panel

• Look openly and critically at individual and organisational practice and the context within which people were working to see whether the incident indicates that changes could and should be made.

• To identify how those changes will be brought about

• To identify examples of good practice.

• Provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence, if possible

• Be written in plain English.

• Contain findings of practical value to organisations and professionals

Staff should be aware that reviews are not part of any disciplinary procedures, but information that emerges in the course of a review may indicate that disciplinary action should be taken under established procedures. Other processes exist for this purpose, including criminal proceedings, coroners’ enquiries, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.

The IMR should begin as soon as a decision is taken to proceed with a review and once the terms of reference have been set.

Any specific documentation supplied for the review should be used in order to enable the use of Chronolator software by the Commissioning Organisation when amalgamating all the chronologies from different agencies.

An example of the IMR Template can be found in Appendix 2 and Chronology Template in Appendix 3

The Reviewing Officer for Provide will review all health records held by Provide, pertaining to the family including any adults identified once consent from the adults is provided via the LSCB/LSAB Consent is not required for a DHR.

Where staff or others are interviewed by those preparing IMRs, a questionnaire will be formulated based on the terms of reference for the review. Interviewees should be given notice of the interview and made aware that they can be supported by a colleague or union representative if they choose. A written record of the interview should be made and then shared with each interviewee in order to verify accuracy before using in the IMR. A note taker or voice tracer which can be transcribed, is recommended if agreed with the interviewee.

Staff should be reminded that the review does not form part of a disciplinary investigation. If the review finds that Provide policies and procedures have not been followed, relevant staff or managers should be interviewed to understand the reasons for this lack of compliance.

The Reviewing Officer will ensure that appropriate support and supervision is offered to staff and interviewees.

The Reviewing Officer will review all relevant case records in order to:

• Complete a comprehensive chronology of involvement by the professionals in contact with the family as set out in the terms of reference for the Review.

• Compile a report which critically analyses service involvement with the family, based on the terms of reference for the review.

The IMR reports should be quality assured by the Chief Executive Officer, who has commissioned the report. The Completed IMR will then be forwarded onto the relevant Board or CCG for inclusion in the Health Overview report.

On completion of an IMR a feedback process and debriefing for staff involved will take place before the completion of the Overview Report. Once the overview report has been completed there should be a follow up session with staff involved prior to publication. As part of the review process, the IMR author will be required to present their report to the review Panel and staff involved may be invited to Practitioner Learning Events held by the Commissioning Board. Staff who have been involved with the family subject to the review should be supported to attend these events and line managers are expected to find cover to enable this.

Any IMR that highlights a concern in regards to the conduct and capability of a member of staff will be referred to their line manager and Human Resource Department/ manager.

Recommendations and Action Plans

The Chief Executive Officer, will be responsible for ensuring that any recommendations from both the IMR and the Overview Report are implemented within the organisation. An action plan based on the recommendations from the IMR and Published review will be developed by the IMR author.

Completion of any action plans or implementation of any recommendations is monitored through the Strategic Safeguarding Group, Quality Provide Leadership Team and the Quality and Safety Committee which reports to the Board

Provide Community Group is required to produce a quarterly progress review on the implementation of the action plans to the relevant Commissioning Board.

7. Dissemination of Learning

Provide is responsible for:

• disseminating the learning from all reviews to their staff.

• supervision and feedback to staff involved in the review process.

Safeguarding Boards and Domestic Homicide Boards are responsible for disseminating learning via:

• Regular Bulletins

• Learning Practice events

• Annual conferences

• Post review learning workshops

• Annual reports

9. SAR Process Map

11. References

• Working Together to Safeguard Children, Statutory Guidance 2018 https://www.workingtogetheronline.co.uk

• The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018 https://www.legislation.gov.uk/ukdsi/2018/9780111167540

• Essex Safeguarding Children Board, SET Child Protection Procedures http://www.escb.co.uk/media/2016/set-procedures-may-2019-final.pdf

• The Care Act 2014

https://www.legislation.gov.uk/ukpga/2014/23/section/44

• Safeguarding Adult Review (SAR) procedure. Essex Safeguarding Adult Board, March 2017

http://www.essexsab.org.uk/media/2022/safeguarding-adult-review-procedure.pdf

• Domestic Abuse Act 2021 https://www.legislation.gov.uk/ukpga/2021/17/section/17/enacted

• Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, Home Office, 2016 https://setdab.org/wp-content/uploads/2018/06/DHR-Statutory-Guidance-2016.pdf

• Tackling Violence against Women and Girls 2021 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/1033934/Tackling_Violence_Against_Women_and_Girls_Strate gy_-_July_2021.pdf

Appendix 1: Example of Safeguarding Adults Review Referral Form

Form SAR 1

ESAB Safeguarding Adults Review Sub-committee considers every referral on the basis of whether it meets the criteria for a Safeguarding Adults Review (see Section 3, ESAB Safeguarding Adults Review Policy)

The Sub-committee needs as much information as possible to enable members to make a proportionate decision as to how to respond to a case referral, ensuring, if the case is accepted for a review, that maximum learning is achieved for ESAB. If you have any questions, please do not hesitate to contact the Safeguarding Adults Board team businesssupport.adultsova@essex.gov.uk

Referrer

Name:

Title:

Agency (where applicable):

Address:

Telephone number:

Email address:

Senior Manager Authorisation (where applicable)

Name:

Title:

Telephone number: Address:

Email address: Date referral Authorised

Adult at risk and person(s) Alleged Responsible to have Caused Harm or Neglect

Adult Subject to Referral:

Name:

Date of birth:

Date of death (where applicable):

Address: Health (physical):

Health (mental):

Agencies involved:

Person(s) or Organisation(s) Alleged Responsible to have Caused Harm or Neglect

Name:

Address: Any additional information:

Appendix 2: Individual Management Review Template

1. Introduction

Brief factual/contextual summary of the situation leading to the review including an outline of the Terms of Reference and date for completion:

• Identification of persons subject to review

• Date of Birth

• Date of death/date of serious injury/offence

• Name, job title and contact details of person completing this IMR (include confirmation regarding independence from the line management of the case).

FAMILY DETAILS IF RELEVANT

Include family tree or genogram if relevant.

2. Terms of reference

3. Methodology

Record the methodology used including extent of document review and interviews undertaken.

4. Details of parallel reviews/processes

5. Chronology of agency involvement what was your agency‘s involvement with the family?

Construct a comprehensive chronology of involvement by your agency over the period of time set out in the review‘s terms of reference. State when the victim/child/family/perpetrator was seen including antecedent history where relevant.

Identify the details of the professionals from within your agency who were involved with the victim, family, perpetrator and whether they were interviewed or not for the purposes of this IMR.

6. Analysis of involvement

Consider the events that occurred, the decisions made, and the actions taken or not. Assess practice against guidance and relevant legislation.

ADDRESSING TERMS OF REFERENCE

Consider further analysis in respect of key critical factors, which are not otherwise covered by the sections above.

7. Effective practice/lessons learnt

8. Recommendations

Recommendations should be focussed on the key findings of the IMR and be specific about the outcome which they are seeking

Appendix 3 Chronology Template

Was the person Seen, If Yes view of the person

Weekday

dd/mm/yyyy

00:00 Paper/electronic/parent/child Record/verbal(who) What, if any concerns identified. Universal,routineoradhoc Include presentation and voice Care Plan, Review, Transfer, Dischargedetc. Policies followed, adequate action plan, appropriate outcome