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3.3 Serious Case Reviews and Other LSCB Audits

SCOPE OF THIS CHAPTER

The Serious Case Review processes outlined in this chapter forms part of the Learning Improvement Framework which covers the full range of reviews and audits which are aimed at driving improvements to safeguard and promote the welfare of children. This policy also describes other LSCB audits.


Contents

1. Serious Case Review Process
  1.1 Criteria for Serious Case Reviews (extracted from Working Together 2015)            
  1.2 Safeguarding siblings or other children    
  1.3 Learning and Improvement         
  1.4 Pan-Dorset SCR Group
  1.5 Referral process of a case which may meet the criteria for a Serious Case Review
  1.6 Decision Making         
  1.7 Notifications about decisions made by LSCB Chair
  1.8 National Panel of independent Experts on Serious Case Reviews
  1.9 Methodology for Pan-Dorset Serious Case Reviews
  1.10 Appointing Reviewers
  1.11 Engagement of families
  1.12 Timescale for Serious Case Review Completion
  1.13 Roles and responsibilities 
  1.14 Engagement of Organisations  
  1.15 Receiving the findings of a Review
  1.16 Publication of Reports
  1.17 Dissemination of findings across the Boards 
  1.18 Retention of Records
2. LSCB Multi-Agency Case Audits
  2.1 Criteria for Multi-Agency Case Audits (MACA)
  2.2 Methodology  
  2.3 Involvement of family
  2.4 Nominated Lead for Review
  2.5 Appointing Reviewers   
  2.6 Findings of the Report
  2.7 Publication of Reports 
  2.8 Dissemination and embedding learning
3. Single Agency Case Audits 
  3.1 Criteria for Single Agency Audit 
  3.2 Methodology for Single Agency Audit
  3.3 Nominated Lead for Audit
  3.4 Single Agency Case Audit Auditor
  3.5 Dissemination and Embedding Learning
4. Domestic Homicide Reviews
  Further Information
  Amendments to this Chapter


1. Serious Case Review Process

1.1 Criteria for Serious Case Reviews (extracted from Working Together 2015)

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:

5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

(2) For the purposes of paragraph (1) (e) a serious case is one where:

(a) abuse or neglect of a child is known or suspected; and

(b) either — (i) the child has died; or (ii) the child has 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.

“Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCBs must commission an SCR.

In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

1.2 Safeguarding siblings or other children

When a child dies or is seriously  harmed, and abuse or neglect is known or suspected to be a factor, the first priority of local organisations should be to consider immediately whether there are other children who are suffering, or likely to suffer, significant harm and who require safeguarding (for example, siblings or other children in an institution where abuse is alleged).

Where there are concerns about the welfare of siblings or other children the core safeguarding procedures should be followed. Once the safety of the child and any other children has been established, organisations should consider whether there are any lessons to be learned about  the ways in  which  they work individually and together to safeguard and promote the welfare of children.

1.3 Learning and Improvement

The purpose of these Serious Case Reviews / LSCB Multi-Agency Case Audits is to identify improvements needed and to consolidate good practice. Agencies should translate the findings into action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.

Working Together 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it should consider the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Learning and Improvement Framework Procedure.

1.4 Pan-Dorset SCR Group

The Pan Dorset Serious Case Review Group meets on a bi-monthly basis. This group is chaired on an alternate basis by Dorset LSCB and Bournemouth and Poole LSCB Executive members.  There are representatives across the LSCBs’ partner agencies. All cases where professionals have significant concerns about multi agency practice with an impact on a child that could lead to potential learning are referred into this group. This includes cases where the criteria for a Serious Case Review may or may not be met.

1.5 Referral process of a case which may meet the criteria for a Serious Case Review

When a practitioner in any LSCB agency identifies a cause for concern or that a case potentially meets the criteria for a SCR or an LSCB Multi-Agency Case Audit, they should initially discuss this with their line manager and agency safeguarding lead in order to agree a way forward.

Where the agency safeguarding lead agrees that the criteria for either a SCR or an LSCB Multi-Agency or Single Agency Case Audit (as set out in these procedures) appear to be met, the request proforma for consideration of a case by the Serious Case Review Group should be completed and counter-signed by the agency safeguard lead. There is a place to select whether the agency safeguarding lead considers this meets the threshold for SCR or MACA and the correct box should be selected.

Request for Consideration of a case by the Serious Case Review Group Proforma.

The proforma should then be submitted to the LSCB SCR Group Chair for consideration via the LSCB Business Manager who will distribute it to relevant individuals. 

Upon receipt of a request for a Serious Case Review or LSCB Multi-Agency Case Audit, the LSCB Business Manager will, with the agreement of the SCR Chair, request a briefing report from agencies known to be involved. This will include at the very least, a report from Police, Social Care, Education (where schools age), GP and Health Visitor (where appropriate). 

A Briefing Report Proforma will be used by each agency to respond.

This will enable agency representatives to be informed and able to discuss the case fully.

1.6 Decision Making

The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria for a Serious Case Review (see Section 1.1, Criteria for Serious Case Reviews (extracted from Working Together 2015). This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).

It is for the Pan-Dorset Serious Case Review Group, after hearing all of the information and the request for a review, to make a recommendation (through the chair of the group) to the Independent Chair of the LSCB who will decide what action will be taken. The flowchart details potential outcomes.

Any Serious Case Reviews and LSCB Multi-Agency Case Audits will be managed in a way that gives the best opportunity for multi agency and whole system learning and will include managers and practitioners in the process wherever possible. All managers and practitioners will be supported to contribute effectively to the process.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review.

The Bournemouth and Poole LSCB (B&P LSCB) and the Dorset Safeguarding Children Board (DSCB) have a process for LSCB Multi-Agency Case Audit, where this is appropriate to use (this is described in Section 2, LSCB Multi-Agency Case Audits). In some cases a single agency audit will be appropriate and the group may ask that the findings are reported back to the SCR sub-group (this is described in Section 3, Single Agency Case Audits).

In some cases, a Domestic Homicide Review will be running concurrently (see Section 4, Domestic Homicide Reviews).

The LSCB Chair should be confident that the agreed 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.

The decision will be communicated to the referring agency. It is the responsibility of the person making the referral to ensure that their concerns are properly addressed to their satisfaction.  Where this is not the case, or concerns remain, the matter should be resolved using the Escalation Procedures.

1.7 Notifications about decisions made by LSCB Chair

The LSCB must notify Ofsted, DfE and the National Panel of Independent Experts (see 1.8 below) within five working days of the Chair’s decision about cases which have been submitted as meeting the threshold for SCR. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the LSCB chair may be asked to give evidence in person to the panel.

The following bodies should be informed:

National SCR Panel: Mailbox.SCRPANEL@education.gov.uk
Department for Education: Mailbox.CPOD@education.gov.uk
Ofsted: scr.sin@ofsted.cjsm.net

After the decision has been taken to proceed with an SCR the Designated Nurse Consultant must notify the CQC.

1.8 National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children 2015 introduced a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews. The panel reports to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.

LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

1.9 Methodology for Pan-Dorset Serious Case Reviews

All Serious Case Reviews will have agreed Terms of Reference and will be formally chaired. The ToR and appointment of a Chair is scoped by the Serious Case Review Group on a case by case basis. The Terms of Reference for a SCR will be agreed by the LSCB Chair. The expectation is that all Serious Case Reviews will be completed in 6 months.

There are a variety of ways in which cases may be Reviewed and it will be the decision of the SCR Group to determine the most appropriate for the particular case. The SCR Group will therefore select one of the following methods for undertaking a Serious Case Review:

  • Partnership Learning Review: A model for conducting Serious Case Reviews is a method which was commissioned by both pan Dorset LSCBs for local use.  This model is based on the systems methodology and therefore serves as a proportionate approach to learning via SCRs, according to the scale and level of complexity of the issues being examined. It also allows for SCRs to be independently led and for the practitioners who were directly involved with the case to be fully involved in the review process and provide clear context for the time being reviewed. There is also a provision for families, including surviving children to be invited to contribute, enhancing the learning from the Review;
  • SCIE Learning Together This is an accredited model based on Systems methodology. The review will always be lead by an SCIE Lead Reviewer. Central to the Review is what is termed the “methodological heart”. This refers to:
    • The avoidance of hindsight bias, this involves speaking to practitioners involved at the time to find out what they knew, how they felt and why they took the actions they did;
    • Identifying Key Practice episodes and seeking to appraise and explain them by involving practitioners as part of data gathering;
    • Finding out if identified issues are indeed systemic and provide a “window on the System”.

This is a relatively prescriptive model where evidence based tools are used to progress the work.

  • Root Cause Analysis sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened;
  • Significant Incident Learning Process (SILP) This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’;
  • Appreciative Inquiry (AI), SCR’s conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong.

1.10 Appointing Reviewers

The LSCB will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews using the Learning and Improvement Framework Procedure, Principles for a Culture of Continuous Improvement. The LSCBs have processes in place to manage the commissioning arrangements for these appointments and this should be followed to ensure compliance with financial regulations.

The lead reviewer should be independent of the LSCB and the organisations involved in the case.

The LSCB will provide the National Panel of Independent Experts (see Section 1.9, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.

Working Together to Safeguard Children 2015 says that reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.

1.11 Engagement of families

The Terms of Reference will indicate the way in which families and siblings might be involved in the review to learn from their experience of service responses.

There is an increasing body of evidence that the family members, including children, can make a valuable contribution to professional understanding.

1.12 Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

1.13 Roles and responsibilities

Role of LSCB Chair

The LSCB Chair holds the ultimate responsibility for the completion of a SCR and  should ensure that it is completed according to Working Together to Safeguard Children 2015.

Role of SCR Group Chair

The SCR Group Chair is responsible for ensuring the SCR is completed according to the model agreed.  This will involve the production of Terms of Reference for the SCR, commissioning an independent lead and managing the process all the way through.

Role of LSCB Business Manager

The Business Manager should oversee the process, draft documents for the SCR Group chair, liaise with report authors, practitioners panel members and be a conduit between the LSCB Chair, SCR Chair and Independent Lead where required. This involves supporting each step in the process and ensuring that the process is kept to timescale.

Role of SCR Group

Identified members of partner agencies should commit and prioritise the SCR ensuring that they contribute to the discussion and share information with their own organisation in respect of the SCR progress.

1.14 Engagement of Organisations

The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

In addition, the LSCB can require a person or body to comply with a request for information Section 14B of the Children Act 2004. This can only take place where the information is essential to carrying out LSCB statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCBs should be mindful of the burden of requests and should explain why the information is needed.

Agencies will be committed to understanding the findings of any review and actively participating in the learning and improvement processes.

1.15 Receiving the findings of a Review

Systemic Reviews will identify Findings and Learning for the LSCB to consider and it is for executive members to identify how any learning can be taken forward. Action plans should address complex systems issues.

The LSCB Board will be facilitated to agree the approach to agreeing and implementing an improvement plan.

The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

The LSCBs will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

The LSCBs will have an active oversight of the improvement plans which are the result of Serious Case Reviews. They will be monitored by the SCR sub-group for B&P LSCB and by the QA Sub-group of the DSCB. Progress will be reported to the Board.

1.16 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report will:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

The LSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, it should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.

Publication Details should be notified to:

National SCR Panel: Mailbox.SCRPANEL@education.gov.uk
Department for Education: Mailbox.CPOD@education.gov.uk
Ofsted: scr.sin@ofsted.cjsm.net

1.17 Dissemination of Findings across the Boards

A synopsis/summary will be widely distributed in all cases where there is learning identified.

Messages from learning will be incorporated into training.

The Embedding Change process will be used across the Board to enable services and teams to consider the learning from SCRs and the implications for them in practice.

1.18 Retention of Records

All Serious Case Review Records will be held for a period of 35 years following the completion of the Review. This will be a mix of paper and electronic records which will be held in a secure archive.


2. LSCB Multi-Agency Case Audits

2.1 Criteria for Multi-Agency Case Audits (MACA)

The SCR sub-group may request a multi-agency case audit in cases where there is serious or potentially serious impact on a child or young person and where there are likely concerns about multi-agency working and there are likely to be lessons to be learnt. There is a standard template for the MACA Report.

2.2 Methodology

All LSCB MACAs will have agreed Terms of Reference and will be formally chaired / overseen. The ToR and appointment of a Chair  is scoped by the Serious Case Review Group on a case by case basis. The Terms of Reference will be agreed by the Chair of the SCR group.

The expectation is that all LSCB Audits will be completed in 4 months.

There are a variety of ways in which cases may be audited and it will be the decision of the SCR Group to determine the most appropriate for the particular case.

The SCR Group will therefore select one of the following methods, or a combination that fits the issues in the case, for undertaking an LSCB MACA:

  • Facilitated Case De-brief Meeting of Practitioners A facilitated de-brief meeting should be facilitated by an independent person or by a manager who has not had any involvement in the practice. The purpose of the de-brief meeting is to reflect on the case and to identify any key learning points. Those involved with the family should by invited to attend in order to discuss the learning. A report detailing the learning points should be produced by the facilitator;
  • Compilation of Agency reports and/or Chronologies This would lead to an Overview Report by a nominated lead with detailing learning;
  • Reflective discussion Review of relevant files and case audit by a nominated person independent to the case and discussion with practitioners. This would lead to an Overview Report detailing learning;
  • Root Cause Analysis sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened;
  • Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’;
  • Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. Audits conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong.

2.3 Involvement of family

The Terms of Reference will reflect whether it is seen as appropriate to involve the family in some way.

2.4 Nominated Lead for Review

The Serious Case Review Group will nominate a lead who will be responsible for checking on progress and reporting back to the Serious Case review Group. This person will be able to facilitate in responding to questions about Terms of Reference of helping to negotiate where the review encounters difficulties. The nominated lead will approve the final draft of the report as being of the expected quality before it is presented to the Serious Case Review Group.

2.5 Appointing Reviewers

An independent lead from an agency not involved in the case may be sought and this will usually be managed through the Serious Case Review Group. This may be a senior manager who has not been involved in the practice or a member of the Pan-Dorset SCR Group who works for a neighbouring authority e.g. Dorset, Bournemouth, Poole. 

2.6 Findings of the Report

The final report of the MACA will be presented to the SCR group for agreement and an action plan developed to respond to the findings.

The Report and action plan will be presented to the LSCB Board.

The Action Plan will be overseen by the LSCB SCR Group / DSCB Quality Assurance Group until it is completed, with updates to the Board.

2.7 Publication of Reports

Any report resulting from the completion of an LSCB Audit will remain confidential to the agencies involved and therefore unpublished. The confidential report will concentrate on the learning for agencies.

2.8 Dissemination and embedding learning

A synopsis will be produced and the Serious Case Review Group will consider whether the findings warrant it being disseminated using the Embedding Change process.

Messages from learning will be incorporated into training.


3. Single Agency Case Audits

3.1 Criteria for a single agency audit

The SCR sub-group may request a single agency case audit in cases where there is serious concern about one or two agency’s practice in a case. There are likely to be lessons to be learnt for that agency but no apparent multi-agency learning is identified.

The SCR sub-group will make a formal request to the LSCB Board member for the agency, setting out the reason for the request, any particular areas of review which they recommend should be in the terms of reference and whether the Group want to be informed of the findings.

3.2 Methodology for single agency audit

The expectation is that all Single Agency Audits will be completed in 4 months.

The agency responsible will therefore select one of the following methods, or another that suits their agency, for undertaking the audit:

  • Facilitated Case De-brief Meeting of Practitioners A facilitated de-brief meeting should be facilitated by an independent person or by a manager who has not had any involvement in the practice. The purpose of the de-brief meeting is to reflect on the case and to identify any key learning points. Those involved with the family should by invited to attend in order to discuss the learning. A report detailing the learning points should be produced by the facilitator;
  • Review of relevant files and case audit by a nominated person independent to the case and discussion with practitioners;
  • Root Cause Analysis sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened;
  • Appreciative Inquiry (AI) rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. Audits conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong.

3.3 Nominated Lead for Audit

The agency will identify a Lead for the review who will be responsible for developing the Terms of Reference and and checking on progress and reporting back to the Serious Case Review Group. This person will be able to facilitate in responding to questions about Terms of Reference of helping to negotiate where the review encounters difficulties. The nominated lead will approve the final draft of the report as being of the expected quality and work with the Auditor and others to make recommendations to address the findings. Where requested, this will be presented to the Serious Case Review Group.

3.4 Single Agency Case Audit Auditor

An Auditor from the agency who has not been involved in the case will be asked to undertake the audit and complete a report, including findings. The Auditor and the nominated lead will work with others to develop the recommendations to address findings.

3.5 Dissemination and Embedding Learning

The agency Executive member and Lead for the Audit will agree the best way to disseminate and embed learning from the audit across their agency.


4. Domestic Homicide Reviews

The Government is committed to tackling violence against women and girls including domestic abuse. As a result they have implemented section 9 of the Domestic Violence, Crime and Victims Act (2004), putting in place statutory domestic violence homicide reviews.

Domestic homicide review means a review of 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:

  1. A person to whom he was related or with whom he was or had been in an intimate personal relationship; or
  2. A member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.

The purpose of a DHR is to:

  • Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
  • 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;
  • Apply these lessons to service responses including changes to policies and procedures as appropriate; and
  • Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.

DHR’s are not inquiries into how the victim died or into who is culpable; that is a matter for Coroners and criminal courts, respectively, to determine as appropriate. See GOV.UK.

When a domestic homicide occurs the Community Safety Partnership (CSP) should be informed in writing of the incident. Overall responsibility for establishing a review should rest with the local Community Safety Partnership.

In Dorset a local agreement is also in place setting out the arrangement that the Adult Safeguarding Board will deliver the Domestic Homicide process on behalf of the Community Safety Partnership.

Should the criteria for a Children’s Serious Case Review also be met following an incident which has also been referred for a Domestic Homicide Review then the Community Safety Partnership, the Adult Safeguarding Board and the Local  Safeguarding Children Board will agree a joint arrangement in order to learn from the circumstances and the practice delivered by agencies.

As the case is considered, there must be a decision taken as to whether reports on the DHR and the SCR need to be completed separately, as DHR reports can be delayed by criminal proceedings.

This joint arrangement will be reached according to the individual needs of the case but will usually form a contribution from the LSCB to the DHR and subsequently, shared learning points resulting from the DHR. 


Further Information

NSPCC Serious Case Reviews Repository

Learning and Improvement Framework

Notifiable Incidents

Serious Case Review Quality Markers – supporting dialogue about the principles of good practice and how to achieve them

Amendments to this Chapter

In August 2017 Section 1.10, Appointing Reviewers was updated to clarify the criteria for appointing reviewers.

End.