Multi-agency Case Audits and Case Reviews

Introduction

Kirklees Safeguarding Children Board undertakes multi-agency audits and in-depth reviews of specific cases to evaluate work that has been undertaken to safeguard and promote the welfare of children. 

• Multi-agency audits look at samples of cases to identify the quality of practice and lessons to be learned in terms of both multi-agency and multi-disciplinary practice.
• Serious case reviews are a statutory requirement for Safeguarding Children Boards to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of chidren.
• Practice reviews consider specific cases in a similar way to serious case reviews, but they are not triggered by a serious incident.  Practice reviews may focus on a single aspect of multi-agency working or a complex case, and offer the opportunity to consider a range of practice. 

Multi-agency Audits

Working Together to Safeguard Chidren (2010) provides for Safeguarding Children Boards to evaluate multi-agency working through joint audits of case files.  Kirklees has developed principles to ensure that all multi-agency audits:

- focus on multi-agency and multi-disciplinary interventions and have a clear focus and clearly defined terms of reference
- focus on current practice, considering interventions that have occurred within the last 12 months (maximum)
- consider interventions that are within the remit of Kirklees agencies
- include a focus on the welfare of the child, other children living in the household, timeliness, communication and engagement with families or other significant adults.

The full principles of audit are available here.

Audit reports:

KSCB completed an audit of pre-birth assessments in February 2011.  The audit report and terms of reference are available here.

Serious Case Reviews

A serious case review is always undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death.  Additionally a serious case review is always considered where:

• a child sustains a potentially life threatening injury or serious and permanent impairment of health and development through abuse and neglect; or
• a child has been seriously harmed as a result of being subjected to sexual abuse; or
• a parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004; or
• a child has been seriously harmed following a violent assault perpetrated by another child or an adult;

and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.  This includes inter-agency and/or inter-disciplinary working.

A serious case review is a formal process of bringing together the records of all agencies that have had involvement with the child and family.  An overview report is produced which provides a complete picture of events. This report contains analysis of contact with the child and family and decision making, it draws conclusions and makes recommendations.  An outline of the serious case review process in Kirklees is provided on a flowchart .

Ofsted is the inspection and regulatory body that evaluates all serious case reviews.  The outcome of evaluations is published on a quarterly basis. The Ofsted report Learning Lessons from Serious Case Reviews 2009-2010 provides analysis of 147 serious case reviews completed between 1 April 2009 and 31 March 2010.

The KSCB flowchart 'How we learn from Serious Case Reviews' shows how agencies act on recommendations and the quality assurance process undertaken by the Board to ensure that required changes are embedded in practice. 

Learning lessons and bringing about improvements in practice are key aims of review processes.  One of the ways in which the Safeguarding Children Board shares information about case reviews is through publication of executive summaries.  These contain a summary of each case, the terms of reference, conclusions and recommendations.

Executive summaries from case reviews completed in Kirklees in the last six months are listed below. 

Serious case review undertaken regarding the death of a child aged two years and seven months:

Statement from the Chair of the Safeguarding Children Board

Executive Summary

Multi-agency Action Plan

After six months executive summaries from serious case reviews are removed from the website.  They can be requested from the Safeguarding Children Board.  Please ring 01484 225218, or email KSCB.Admin@kirklees.gov.uk

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