
This protocol outlines the processes for identifying serious child safeguarding cases, conducting Rapid Reviews, and the undertaking of local Child Safeguarding Practice Reviews (CSPR’s), where required.
1. Introduction
1.1 Working Together to Safeguard Children 2023 (Chapter 5) outlines how safeguarding partners must make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area.
1.2 The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a local level with the safeguarding partners. Safeguarding partners must:
- identify and review serious child safeguarding cases which, in their opinion, raise issues of importance in relation to their area
- commission and oversee the review of those cases if they consider it appropriate
2. Serious Child Safeguarding cases
2.1 Serious child safeguarding cases are those in which:
- abuse or neglect of a child is known or suspected
- the child has died or been seriously harmed
2.2 Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social, or behavioural development. This is not an exhaustive list. When making decisions, judgement should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred.
2.3 Notifications of Serious Child Safeguarding cases must always be made if abuse or neglect is a cause of, or a contributory factor to, the serious incident or harm, or where it is suspected. However, where the family is known to Children’s Social Care because of a recent incident or current concern about abuse or neglect and where there has been for example a suicide or unexplained death, professionals should also consider the incident as serious.
2.4 The local authority, on behalf of the safeguarding partners, has a duty to notify the National Child Safeguarding Practice Review Panel about all serious incidents that meet the criteria via the Child Safeguarding Online Notification System. It should do so within five working days of becoming aware it has occurred. Though the responsibility to notify rests on the local authority, it is for all three statutory safeguarding partners to agree which incidents should be notified in their local area.
2.5 When a professional becomes aware of a case that they believe may meet the criteria of a ‘Serious Child Safeguarding case’ as outlined above, they should complete a ‘Serious Incident Notification Request Form’ and submit this to the Safeguarding Children Partnership for consideration. This should be sent to:
For Hartlepool or Stockton - HSSCP@hartlepool.gov.uk
For Redcar and Cleveland or Middlesbrough – STSCP@middlesbrough.gov.uk
2.6 Within two working days of the Serious Incident Notification Request Form being received, the Safeguarding Children Partnership will convene a teleconference in which the Delegated Safeguarding Partners (DSPs) will consider the circumstances of the case and make a collective decision over whether or not the notification will be made to the National Child Safeguarding Practice Review Panel. The Independent Scrutineer is also invited to attend. Where the decision is reached that a notification will be made, the partnership Business Unit will forward the Serious Incident Notification Request Form to the Local Authority Serious Incident Notifier. These are:
Hartlepool: leanne.stockton@hartlepool.gov.uk
Stockton-on-Tees: nicole.wilson@stockton.gov.uk
Middlesbrough: Dawn_Alaszewski@middlesbrough.gov.uk
Redcar and Cleveland: Victoria.McLeod@redcar-cleveland.gov.uk
2.7 Where the decision is reached that a notification will not be made, the partnership Business Unit will reply to the referrer on behalf of the DSPs, outlining the rationale for this decision. Where there is disagreement, the safeguarding partners should follow the ‘Professional Challenge, Escalation and Dispute Resolution’ procedure.
3. When the criteria for a serious incident notification is not met
3.1 In some cases, a ‘serious child safeguarding case’ may not meet the criteria for a serious incident notification but may nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near-miss’ incidents. In this instance, a ‘Learning Request Form’ can be submitted to the Business Unit of the respective Safeguarding Children Partnership.
3.2 The partnership will consider the request and make a collective decision in respect of whether or not there would be learning gained from exploration of the case. Where it is felt there is learning to be gained in respect of how two or more agencies have worked together to safeguard children, a learning review may be convened. Where it is felt that a learning review would not be required, a response will be sent to the referrer, outlining the rationale for this decision.
3.3 A case does not need to have been first considered for serious incident notification in order for it to be considered for a learning review. Professionals are able to submit learning requests via the ‘Learning Request Form’ on any cases which they feel are ‘near miss’ cases and / or if they believe there is learning in respect of how two or more agencies have worked together to safeguard children.
4. When the criteria for a serious incident notification is met - Rapid Review
4.1 Where the criteria for a serious incident notification is met, the notification is made by the Local Authority on behalf of the safeguarding partners via the Child Safeguarding Online Notification System, within 5 days of becoming aware of the incident. The Serious Incident Notifier informs the partnership Business Unit that a notification has been made. The National Panel also informs the partnership via email that they have received a notification.
4.2 Once the Safeguarding Partnership are aware that a Serious Incident Notification has been made, they will commence the Rapid Review process. Safeguarding Partners have 15 working days from the date of notification to informing the National Panel of the Rapid Review decision.
4.3 The details of the incident / case will be shared with the key Safeguarding Partnership representatives; who will become the Rapid Review panel members. One of the panel members will take on the role of Rapid Review chair. The details will also be shared with all involved agencies and chronologies / summary of involvement will be requested.
4.4 Attendance at the Rapid Review meeting will be made up of the Rapid Review panel (Safeguarding Partnership representatives) and representatives from all involved agencies. These will usually be the professionals who have completed the chronology or summary of involvement for their agency. Front line practitioners, who have had direct involvement with the child and / or family, may also be requested to attend. Each partner agency and named relevant agency has a duty to contribute to the rapid review where requested. It is essential that professionals respond promptly to any correspondence in relation to a Rapid Review; due to the tight 15 working day turn around.
4.5 During the Rapid Review, agency involvement will be discussed. Panel members will:
- 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;
- 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 a Local Child Safeguarding Practice Review (CSPR) or recommend that a National CSPR be considered. If the decision is taken not to proceed with a Child Safeguarding Practice Review, members will provide a summary of why it does not meet the criteria.
4.6 Following the Rapid Review, a Rapid Review report will be shared with the partnership Executive members and a review governance meeting will be held. The Rapid Review chair will be invited to attend to share the findings of the review and report with Executive members. The Executive members will consider the recommendation(s) of the Rapid Review panel and report and make the final decision over whether or not the criteria for a local Child Safeguarding Practice Review has been met and will be commissioned. It is for safeguarding partners to determine whether a review is appropriate, given that the purpose of a review is to identify improvements to practice. Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. The criteria safeguarding partners must take into account include 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
- highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children
- highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children
- is one the national panel has considered and has concluded a local review may be more appropriate
4.7 Safeguarding partners should also have regard to circumstances where:
- they have cause for concern about the actions of a single agency
- there has been no agency involvement, and this gives them cause for concern
- more than one local authority, police area or ICB is involved, including in cases where a family has moved around
- the case may raise issues related to safeguarding or promoting the welfare of children in institutional settings
4.8 These form part of the questions asked as part of the Rapid Review meeting and are included within the Rapid Review Report to aid the decision-making of the Executive members.
4.9 The partnership chair will add the final decision to the Rapid Review report and this will be submitted to the National Panel, informing them of the outcome. This is submitted to the National Panel within 15 working days of the serious incident notification. The National Panel will aim to respond to the submission, to indicate whether or not they agree with the outcome, within 15 working days.
5. Local Child Safeguarding Practice Review (LCSPR)
5.1 Where the outcome of the Rapid Review has indicated that the criteria for a local Child Safeguarding Practice Review has been met, the Safeguarding Partnership will commission and undertake the review. Safeguarding Partners have 6 months from the date of the decision to complete the review and publish the final report.
5.2 The Safeguarding Partnership will commission a lead reviewer, agreeing with the reviewer(s) the method by which the review should be conducted, taking into account the principles of the systems methodology recommended by the Munro review. The methodology should:
- provide a way of looking at and analysing frontline practice as well as organisational structures and learning.
- be able to reach recommendations that will improve outcomes for children and should reflect the child’s perspective and the family context.
The review should be proportionate to the circumstances of the case, focus on potential learning, and establish and explain the reasons why the events occurred as they did. Each LCSPR may be undertaken differently depending upon the agreed methodology.
5.3 Once the methodology and Terms of Reference are agreed, the Safeguarding Children Partnership will identify those agencies required to contribute to the LCSPR. This may be informed by the Rapid Review which will have already taken place. Each partner agency and named relevant agency has a duty to contribute to LCSPRs where requested. This may involve submitting chronologies or reports and / or attending learning events or focus groups. Details of what is required will be shared by the respective Partnership Business Unit as well as deadlines for submission of information. It is essential that professionals adhere to the deadlines and timeline of the review, in order that the partnership can meet the statutory timescale for completion.
5.4 The reviewer will produce a report containing recommendations for the Partnership. Any recommendations should make clear what is required of relevant agencies and others both collectively and individually, and by when, and focussed on improving outcomes for children. Partnership representatives will share responsibility for the progression of recommendations and any changes or improvements needed about the way in which organisations and agencies work together to safeguard and promote the welfare of children. The progress of recommendations will be monitored by the respective Safeguarding Children Partnership.
5.5 LCSPR reports should be published 6 months following the decision to initiate the review and reports or information must be publicly available for at least one year. A copy of the full report is shared with the national panel, the Secretary of State and Ofsted no later than seven working days before the date of publication.