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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.

 

When the PSCP becomes aware of a serious incident involving a child the PSCP is required to consider carrying out a Child Safeguarding Practice Review (CSPR) into the involvement of organisations and professionals in the lives of the child and their family.

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 physical health, mental health or intellectual, emotional, social or behavioural development. (This is not an exhaustive list).

The purpose of a CSPR is to:

  • establish whether there are lessons to be learnt from the case about the way local professionals and organisations work together to safeguard and promote the welfare of children
  • identify what those lessons are, how they will be acted on, and what is expected to change as a result, and therefore, improve inter-agency working and better safeguard and promote the welfare of children.

Chapter 4 of Working Together 2018 sets out in full the statutory responsibilities and process for LCSPRs.

A CSPR is not a criminal enquiry and is separate from an investigation undertaken by the police. This process is not about blame or any potential disciplinary action, but about an open and transparent learning from practice to improve inter-agency working.

Please see this One Minute Guide for further information.

  1. Abuse or neglect of child is known or suspected, and
  2. The child has died or been seriously harmed

Meeting these criteria does not mean that the PSCP must automatically carry out a CSPR. Woking Together also sets out additional criteria that the PSCP must consider before commissioning a review. These 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

Locally it is for the Learning from Cases Committee (LFCC), on behalf of the PSCP, to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice.

Each agency must have arrangements for identifying cases that may meet the criteria for a CSPR.

  • Any partner / relevant agency can refer a case to the LFCC
  • All serious incidents that the Local Authority has notified Ofsted about must be referred to the LFCC
  • All professionals referring cases should initially discuss the case with their agency representative at the LFCC for approval
  • Referral forms should be submitted to the Partnership Team at PSCP@portsmouthcc.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 practice undertaken in the case, highlighting strengths and areas of challenge

The referral form can be found here.

Once a referral has been received and discussed with the LFCC Chair. If this has come following a Serious Incident Notification then a Rapid Review will always be conducted. If the referral has been sent via another route then it will be assessed and, if necessary, further scoping will be requested to consider whether it may meet the criteria for a CSPR.

  1. Rapid Review
  • Completed within 15 working days of an incident being notified to the PSCP
  • Practitioners complete Rapid Review Scoping Forms
  • LFCC complete a rapid review form which is sent to the National Panel.
  1. Scoping
  • Completed at the next scheduled LFCC meeting
  • Practitioners complete the scoping forms.
  • LFCC members discuss the response forms and decide how best to ensure learning is identified and disseminated

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; and
  • decide what steps they should take next, including whether or not to undertake an CSPR

 

On agreement that a case meets the criteria for a CSPR a panel of senior managers who were not directly involved in the case will meet to look at the work of all the professionals and agencies who have been involved, and set terms of reference under which the review will be undertaken. Each organisation will produce an independent report containing full details of when and what services they gave the family.

The CSPR panel will be supported and advised by an independent reviewer, who is a specialist in child protection and CSPR. The reviewer considers all the reports and writes an independent overview report that looks at whether expected standards of practice have been met, if policies and procedures were followed, and whether there are any lessons that can be learned about the way organisations work together to keep children and young people safe.

When a review has been completed, organisations will agree what actions they need to take to change the way they support children, young people and their families and these will be monitored by us.

Timescales

We aim to complete reviews within six months, however, this timescale may be impacted by other parallel processes, such as criminal investigations, coroner inquests, or family proceedings.

Practitioner involvement

Once a decision has been made to start a CSPR, we will ask the relevant agencies to identify authors to write their independent agency report. The authors will be invited to attend an author’s briefing where they will meet the independent reviewer and receive guidance on what is required for the report.

Following this, the authors will be encouraged to identify any practitioners within their agency who worked with the family. They will meet with you to discuss the case, your involvement, and your perspective on what aspects of the system influenced you as a worker. The author from your agency will provide you with a letter from the independent reviewer, explaining the review process and inviting you to practitioner learning events.

The style and format of the practitioner learning events may vary for each review; however, the aim is for all the practitioners who worked with the family during the agreed timescales to meet and discuss their views and identify key learning areas from the case.

Part of the role of your agency’s report author and panel member is to provide support to you during this process and you will be allowed to bring a colleague with you for support at practitioner’s meetings.

Please note that if there is a police investigation ongoing regarding the case and you are called to be a witness as part of the proceedings, this may cause delays in contacting you and discussing your views.

Family engagement

Family members will be given the opportunity to contribute to the CSPR process by considering the services and support provided by various agencies and whether this was appropriate to their needs. Family members may also be asked to comment on issues associated with the publication of the final review. Which family members are contacted and at what point in the review will be determined on a case-by-case basis. It may not be possible to speak to some members due to concurrent criminal investigations or trials. Family members are not just parents / carers but will include extended family as appropriate.

It is recognised that contacts with family members should be handled sensitively and, where possible, via a professional already known to the family.

The final overview report will be published on our website, unless it is harmful to other children to do so or cannot be published in any way that avoids identifying those involved. All reports are anonymised for publication and can be found by following the links to the right of this page.

We will make sure that the report is shared with you before it is published via your agency author or agency panel member.

The report will include:

  • 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
  • Recommendations of what is required of relevant agencies and others collectively and individually, and by when, and focussed on improving outcomes for children

Prior to September 2019, LCSPRs were referred to as Serious Case Reviews (SCRs).

Complexity and challenge: a triennial analysis of SCRs 2014-2017, published in March 2020 by the Dept. for Education.

Research in Practice has produced material to support learning from the triennial analysis for social work; early help; police and criminal justice; health; and education practitioners.

The NSPCC hosts a national case review repository, where you can find a library of all LCSPRs (and Serious Case Reviews) conducted in England

The NSPCC has also produced a series of thematic briefings on learning from case reviews which can be found here.

In 2016 the NSPCC and SCIE published Learning into Practice: inter-professional communication and decision making – practice issues identified in 38 serious case reviews. From this they produced 14 briefings on the practice issues identified in this report relating to how professionals in different agencies communicate and make decisions. These are intended to support services consider whether similar issues may be occurring for them locally, and how they might tackle them. Each briefing contains a set of self-assessment questions to support this process.