Chapter 41: Serious Case Review Process - Working Draft

Introduction

A recent Ofsted report (Dec 2008) evaluating 50 serious case reviews carried out between 1 April 2007 and 31 March 2008 presented these key messages:

Most delays caused by:

• Inability to appoint independent authors
• Internal staffing pressures preventing work being done
• Difficulties in securing the co-operation of relevant agencies
• Complexities of coordinating serious case reviews which cover more than one local area or a number of different agencies
• Inexperience of staff conducting individual management reviews
• Parallel investigations such as coroner's courts and criminal proceedings
• Delays in agreeing final set of recommendations and action plan between agencies.

Reasons for inadequate judgements included:

• Terms of reference unclear
• No agreed format for completion of individual management reviews
• Presentation poor with a complacent approach to the task; absence of basic information Insufficient analysis or critique of practice with a defensive stance rather than open and critical approach to learning lessons
• Key issues not recognised or addressed
• Lack of recommendations that clearly specify how lessons learned will be translated into practice
• Recommendations limited, not relevant to findings, vague and unspecific about time scale for implementation
• Action plans with no clear process for monitoring the implementation or impact of the action plan, in particular no formal role for the LSCB in monitoring and evaluating the impact of the action plan on inter-agency working.

Purpose of the SCR

The purpose of SCR's is to:

• Establish whether there are lessons to be learned from a case about the way in which local professionals and agencies work together to safeguard children
• Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and hence
• Improve inter-agency working and better safeguarding of children.

Criteria for Convening Serious Case Reviews

The same criteria apply to disabled children as to non-disabled children. A case review must always be held when:

• A child dies (including suicide) and abuse or neglect is known or suspected to be a factor.

Additionally a SCR may be held when:

• A child has sustained a serious or life threatening injury or serious and permanent impairment of health or development through Abuse or Neglect and the case gives rise to concerns about the way in which local professionals and services work together.
• A child has suffered serious Sexual Abuse
• Their parent has been murdered (including domestic violence situations) and a homicide review is being initiated
• The child has been killed by a parent with mental illness

In cases where a child has not died it may be appropriate to hold a SCR if one or more of the following criteria are met:

• There was a significant risk of harm to a child which was unrecognised by agencies or professionals in contact with the child or alleged perpetrator, or not shared with others or not acted upon properly
• The child was abused in an institutional setting, e.g. school or family centre
• The child dies in a custodial setting
• The child dies whilst absent having run away from home
• The child was being Looked After by the local authority at the time of abuse
• Agencies or professionals consider that their concerns were not taken sufficiently seriously or acted upon appropriately by another
• The case indicates that there may be failings in one or more aspect of the local operation of formal child protection procedures which extend beyond the handling of the case
• The child was, or had been, subject to a Child Protection Plan or deemed to be at the threshold of risk of Significant Harm.
• The case appears to have implications for a range of agencies or professionals

Ofsted's Role and Contribution

The individual aspects of a serious case review considered in the evaluation include the following.

• whether it was appropriate to instigate the review
• the scope and time period covered by the review
• the terms of reference and whether the author is suitably independent of the agencies involved
• whether the review was completed within recommended timescales
• the quality of the individual management reviews
• whether the ethnic, cultural, linguistic and religious needs of the child and family were met by services, and are addressed within the review
• whether the family were invited and enabled to contribute to the review process
• the quality of the overview report, including:
  • background information
  • rigour of analysis and challenge of information in IMR's
  • joint chronology
  • appropriate recommendations
  • reference to research and previous review findings
  • joint agency action plan with clear targets and timescales
  • monitoring arrangements by the LSCB
• the quality of the executive summary, including whether it is suitably anonymised to protect the family's identity, and whether it is yet published.

Summary of ESCRP Role and Responsibilities

• The referral form (appendix 1) to be completed by the referring agency and sent to the Chair of ESCRP with a copy to the BLSCB Business Manager.
• The ESCRP has 1 month to reach a decision that the case meets the criteria for a SCR and a meeting of the ESCRP is convened within 5 working days of the referral being received.
• When the ESCRP decides that the criteria are met, the ESCRP will undertake / commission a SCR according to the guidelines set out in Chapter 8 of Working Together to Safeguard Children 2010.
• The ESCRP will commission IMR's and draw up clear terms of reference including timescales for the  review within 4 months and identify who should be on the Serious Case Review Project Group (SCRPG). The SCRPG will undertake the SCR and report back to the ESCRP as per the Terms of Reference.
• ESCRP will ensure that an Overview Report, with recommendations for action is produced which brings together the information and analysis contained in the IMR's together with reports commissioned from any other relevant parties, using an outline that clearly reflects both guidance in Working Together 2010 and the agreed Terms of Reference.
• ESCRP will ensure that all IMR's have been signed off by the Chief Officer or nominated deputy of each organisation and that if necessary, their own legal advice has been sought and considered.
• ESCRP will appoint a SCR author who will work directly on and write the Overview Report on behalf of the ESCRP.
• ESCRP will give adequate consideration to the impact of parallel processes e.g. criminal investigations, disciplinary procedures and advise the LSCB accordingly.
• ESCRP will consider the wider issues of accountability and disclosure. The ESCRP will identify who might have an interest in SCR's and consider what information should be made available to each of these interested parties. The advice and guidance of the associate members of the ESCRP for e.g. Communications staff, Legal Services, Information and Clinical Governance staff will be of value in these discussions.
• ESCRP will ensure the timely production of an anonymised Executive Summary.
• ESCRP will develop and coordinate a communications strategy to ensure that the lessons learnt from SCR's can be shared and made public.
• Treat all papers relating to the ESCRP's work as confidential.
• BLSCB Administrator will mark copies of all Overview Reports as draft until the report is approved and arrange for draft reports to be destroyed.
• ESCRP will keep papers locked and secure during the process of a SCR.
• ESCRP will retain a single copy of the Overview Report.
• ESCRP will destroy all other papers.
• ESCRP will make arrangements for the secure retention of a single copy of their own IMR's and the Overview Report.
• ESCRP will ensure that all draft copies of the Overview Report are shredded.
• Once the final copy of the SCR and Action Plans has been agreed and signed off by the ESCRP and Strategic Board and its recommendations accepted then ESCRP members will be free to destroy all copies of the report as the original will be kept by the BLSCB Administrator.
• BLSCB Administrator will retain copies of all papers associated with a SCR for a period of 7 years.
• BLSCB Administrator will provide access to papers through application to the Chair of BLSCB.

Summary of ESCRP Reporting and Notification Arrangements

• Director of Children's Services to identify local authority member of ESCRP who will have responsibility to notify Ofsted and the Department for Education each time a decision is made to undertake an SCR. This will normally be the BLSCB Business Manager.
• PCT representative on BLSCB to identify member of ESCRP who will have responsibility to notify Strategic Health Authority (SHA) each time a decision is made to undertake an SCR.
• The BLSCB Business Manager will provide monthly update of SCR's including progress and planned dates for completion to Ofsted and SHA.
• ESCRP chair and members to ensure that the BLSCB and Chief Executive Officers of relevant organisations are briefed about the work of the ESCRP on a regular basis.
• ESCRP to receive IMR's and agree single agency recommendations.
• ESCRP will negotiate and agree extensions where a SCR cannot be completed within 6 months.
• ESCRP will ensure that once the Overview Report is completed and accepted by the BLSCB, the Executive Summary / full report as agreed is circulated to agencies relevant to the case.
• ESCRP will agree the recommendations of the final overview report and will produce an action plan addressing those recommendations.
• ESCRP will ensure that the  final  report (with action plans and IMR's ) is sent to Ofsted and the Department for Education.
• ESCRP will monitor the action plans from the Overview Report (IMR actions will be monitored on an exception basis). The Strategic Board will receive a regular report on progress, will include consideration of the strategic and multi agency issues raised by the review in the work programme for the performance management group and will ensure that relevant issues are addressed through the annual business plan.
• Partner agencies will be responsible for monitoring their individual action plans and reporting to the ESCRP on their progress as requested.

Membership

The expectation is that membership of the group will remain constant and that each representative will commit to a term of 2/3 years in order to provide group stability.

In selecting representatives, each agency will:

• Choose a member of staff who is able to represent the organisation's views policies and practice and has been given the mandate to do so.
• Choose a person with sufficient experience and knowledge of the field to inform the debate and the matters under consideration.
• Ensure that representatives have sufficient time allocated to enable the representative to effectively undertake the work of the ESCRP.

Quoracy

As a matter of principle members of the panel will not combine this role with that of conducting IMR's. This could lead to a conflict of interest and prejudice their independence. Membership is drawn from core members of the BLSCB:

Core Members

• BLSCB Independent Chair
• Bedford Borough Assistant Director Children's Social Care
• Bedford Borough Chief Officer Education
• Central Bedfordshire Head of Learning and Schools
• Central Bedfordshire Deputy Director Children Social care
• NHS Bedfordshire Commissioning Services (Designated Doctor and Nurse for Safeguarding Children will provide advice and guidance the Executive Nurse).
• Bedfordshire Community Health Services
• Bedfordshire Police

Officers

• Principal Lawyer from either Bedford Borough or Central Bedfordshire and Legal Adviser to BLSCB
• BLSCB Business Manager
• BLSCB Administrator

Role of Legal Advisor

The role of the Legal Advisor to the ESCRP may include:

• Liaison with other agencies in particular the Police and Crown Prosecution Service to ensure that the SCR process does not conflict with actual or potential prosecutions or appeals
• Analysis of new case law/ statute affecting the SCR process
• Ad hoc advice to the Chair of the ESCRP and to the Overview Report Author

The main focus of legal advice provided to ESCRP is to ensure that the review fulfils its purpose by being widely and appropriately disseminated without exposing BLSCB to unnecessary legal challenge. To achieve this aim:

• IMR's and Overview Reports should be based on clear, logical and lawful Terms of Reference
• Evidence should be clearly sourced. Direct first hand evidence should be given most weight. Where allegations cannot be substantiated by such evidence, it must be clearly identified as unsubstantiated and weighed carefully against other or more reliable evidence
• If allegations are made against individuals in a report those individuals should be given the opportunity to respond before such allegations are included within the final report
• Specific advice should be sought on technical issues e.g. Data Protection, Court rules etc

Disclosure of Information

The ESCRP should consider all of the stakeholders of the SCR and independently consider the following questions:

• Is there a legitimate purpose for the information within the SCR to be shared with the stakeholder?
• Does the information enable a person to be identified? Can the data be anonymised? If the information allows an individual to be identified, the agencies must take reasonable steps to explain what information will be shared, and why, taking into account data protection legislation
• Is the information confidential?
• Has Consent been obtained? Remembering to confirm what constituted consent, whose consent was obtained and when it would not be appropriate to seek consent
• Is there a statutory duty to share information? The most significant test in this area when considering SCR's is the sharing of information under the public interest test. This test is at the heart of the Freedom of Information Act 2000. In forming a judgement on this, ESCRP should consider factors for and against including:
  • Will disclosure further the public's understanding of significant issues
  • Will disclosure promote public accountability and transparency
  • Will disclosure allow the public to understand decisions made by public bodies
  • Will disclosure bring to light information affecting public health and safety
  • Will disclosure affect law enforcement
  • Will disclosure impact on the European Convention of Human Rights
  • Is the information an exemption under the FOIA

It is important to bear in mind that the competing interests are the public interest not private interests. There will often be a private interest in withholding information. Concerns that information may be too complicated for the public to understand is not a good ground for non disclosure. The ESCRP should also consider precedent and cases considered by the Parliamentary commissioner. The default position will be to consider the need to know as opposed to the want to know.

• What systems and processes will be used to share the information? This means considering only sharing the information which is necessary for the purpose for which it is being shared, sharing it with those who need to know, checking that the information is accurate and up to date, sharing it in a secure way, establishing with the recipient whether they intend to pass it onto other people and ensure that they understand the limits of any consent and finally informing the person the information relates to (and / or the person who shared the information) if they are not aware and it is safe to do so.
• Record the decisions made in a formal way.

Information held and/ or gathered by agencies for the purpose of a SCR may fall within one or more of the following exemptions:

• Investigations and proceedings conducted by public authorities (e.g. a criminal investigation).
• Court records
• Health and safety (disclosure would be likely to endanger the physical/ mental health/ safety of an individual).
• Personal data - Defined in Data Protection Act 1998 as "Data which relates to a living individual who can be identified from those data and any other information in the possession of or likely to come into the possession of the data controller - which includes opinions about the individual and indications about intentions in respect of the individual."
• Information provided in confidence (disclosure would constitute a breach of confidence).

Some exemptions are absolute, others are qualified - requiring a balancing exercise to be carried out before a decision is made as to whether to disclose. Agencies should consult their information officer or take legal advice if in any doubt as to whether an exemption applies.

NB Requests by an individual involved with the SCR, for information concerning them would be dealt with in accordance with the Data Protection Act.

The Criminal Procedure & Investigations Act 1996 and Disclosure of Information in Criminal Proceedings

Timescales

Given that the primary purpose of SCR's is to contribute to the improvement of inter-agency practice, the ESCRP should ensure that lessons are learned and acted upon as quickly as possible (Working Together, 8.22, 2010).

• Working Together 2010 (8.22) states that "within one month of a case coming to the attention of the BLSCB Chair who along with the ESCRP will consider the case to make a recommendation on whether the criteria for a SCR are made.
• The SCR should be completed within a further 6 months, "unless an alternative timescale is agreed with Ofsted and the Department for Education at the outset" (8.23).

Delay

Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it is clear that a SCR cannot be completed within the 6 month timescale, there should be discussion with Ofsted to agree a timescale for completion (8.24).

• SCR's should not be delayed as a matter of course because of outstanding criminal proceedings, or a pending decision as whether or not to prosecute (8.25).

Referrals

First Meeting of Executive Serious Case Review Panel

Agency Notification

Notifying Ofsted / Children's Services Advisor at DfE (GO East)

If necessary the following should be informed as appropriate:

• Department for Education Children's Safeguarding Unit should be informed immediately of all deaths of looked after children
• Department for Education Early Years Unit and Ofsted should be informed if children's day care or childminding is involved.
• Department for Education, Ofsted, SHA and DOH should also be informed if a school is involved.

Notifying Families

Notifying Victims

Criteria for Serious Case Review not met

There may be cases where the ESCRP decides that the criteria are not met and in these circumstances the ESCRP may consider conducting a review under the following two categories:

Interagency Practice Reviews (IPR)

Near Miss Review (NMR)

Agreeing Terms of Reference / Scoping the SCR

Author of Overview Report

Process for Appointing an Independent Overview Report Author

The ESCRP has responsibility for identifying suitable candidates. For all externally appointed Authors, a minimum check will include:

• A CV
• An example of an Overview Report recently written by them
• A written reference from a Senior Manager/LSCB Chair in an authority where they have recently written an Overview Report
• A face to face interview with the candidate to confirm that their method of working is congruent with the values and principles laid down in this practice guidance maybe undertaken dependent on timescales and previous knowledge of the Overview Report Writer
• CRB check

For all in house appointed Authors, a minimum check will include:

• A written reference from their line manager expressing support in terms of supervision and time allocation for the individual to undertake the review
• Confirmation that an enhance CRB check has been completed within the last 3 years.

Commissioning a Contract With the Overview Report Writer

Individual Management Reviews (IMR's)

Sign off of IMR's

Presentation of IMR's to Executive Serious Case Review Panel

The Executive Summary

The primary purpose of the Executive Summary is to inform a wider population of the organisations involved, and the public, of the key elements in the SCR, namely:

• Introduction - role of BLSCB and ESCRP and purpose of the SCR
• Background/ Case Summary - anonymised summary of the case and the key themes arising form the case review
• Case Specific Recommendations/lessons learned - acknowledge recommendations, action plans and timescales. Identify monitoring and reviewing process
• Recurring themes - relationship of the individual case review to previous local and/or national enquiries
• Implications for future /communication strategy - professional practice including highlighting good practice and procedural issues and implications for interagency procedures.

The Executive Summary can be used in the following way:

• A demonstration of the way in which BLSCB has exercised its responsibilities in relation to death or injury of child/children.
• A basis for press briefings should the SCR process attract media attention.
• An efficient means of informing Chief Officers and the inter-agency practice community of key learning arising from the review of practice.
• Core information upon which to build more elaborate case specific training materials.

Accountability and Disclosure

BLSCB should consider carefully who might have an interest in SCR - e.g.: elected and appointed members of local authorities, health trusts, police authorities; staff, members of the child's family, the public, the media - and what information should be made available to each of these interests.  There are difficult interests to balance, among them:

• The need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others.
• The accountability of public services and the importance of maintaining public confidence in the process of internal review.
• The need to secure full and open participation from the different agencies and professionals involved.
• The responsibility to provide relevant information to those with a legitimate interest, and
• Constraints on sharing information when criminal proceedings are outstanding, in that providing access to information may not be within the control of the BLSCB.  The Police Superintendent, as representative on the ESCRP, will need to notify the officer in charge of the criminal investigation of the existence of the Overview Report.

Submission of the SCR and Publication of the Executive Summary

The ESCRP will need to consider a publication strategy to make public the lessons learnt as part of the review. The ESCRP should consider carefully who might have an interest in reviews, for example, elected and appointed members of authorities, staff, members of the child's family, the public, the media - and what information should be made available to each of these interests. There are difficult interests to balance, among them:

• the need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others;
• the accountability of public services and the importance of maintaining public confidence in the process of internal review;
• the need to secure full and open participation from the different agencies and professionals involved;
• the responsibility to provide relevant information to those with a legitimate interest;
• Constraints on public information sharing when criminal proceedings are outstanding, in that providing access to information may not be within the control of the BLSCB.

The key outcomes of a communications strategy will be to:

• To provide information in a clear and consistent way
• To concentrate on the lessons learned and what is and what has been done to address them
• To support the family of the victim and engage them in the launch of the report

When developing a communications strategy, the ESCRP will need to consider the following:

• Key messages
• Key audience
• Types of processes used to make public the lessons learnt, options include, press release, use of website, press conference etc
• Roles and responsibilities of key individuals
• To identify which agency will provide a communication lead including the issuing of press releases on behalf of BLSCB which will be independent from any briefings from other agencies involved in the SCR
• Support offered to families
• Briefing of staff on the contents of the report
• Briefing of the families and those involved in the compilation of the report
• Available resources for publication
• Debriefing arrangements to those involved
• The need for media training

Retention of Papers

Finalisation and Adoption of the Overview Report

Ofsted / DfE /GO East

Once adopted, the following documents must be sent to the Ofsted / DfE/GO East:

• IMR's, including the chronology, and recommendations
• The Overview Report
• Integrated Chronology
• Executive Summary
• Agency Action Plans (agencies other than Local Authority Children's services will need to consent to this)

A Strategy for Learning and Support

It proposes to do this using:

• Case study materials to support learning
• Debriefings for those involved in cases where a serious case review has been undertaken
• Practitioner briefings
• Briefings for managers
• Newsletters- to share learning from reviews
• Focused training (where specific needs are identified).

Case Studies

De-Briefing for Those Involved in the SCR

Following adoption/endorsement of the Overview Report and the development of an Action Plan, practitioners directly involved in the case will be invited to a de-briefing meeting.

The purpose is to:

• Give feedback on the Overview Report, Recommendations, Action Plan and messages for learning from these, in advance of dissemination to the wider system
• Where possible, a member of the ESCRP and the Training and Development Commissioning Manager will be present in order to offer further clarification of practice issues arising from the SCR.

For the purposes of the meeting, those attending will be sent a hard copy of the Overview Report in advance. This will be handed back to the BLSCB Administrator at the end of the meeting.

Aims:

• Involvement: to appropriately involve all practitioners dealing directly with the case.
• Clarification: this is an opportunity to clarify and discuss the SCR process and its purposes. It is a highly anxious time for practitioners when there may be ongoing work with a family: juggling ongoing operational issues and being open to the perceived scrutiny of the SCR process, being interviewed by the Single Agency Management Review author etc.
• Participation: it provides the opportunity to meet other professionals who are in the   same boat and also to discuss their often-differing experiences within their agency. For example: support, sealing files, reactions/responses from colleagues.
• Support: Some practitioners are well supported through the intense scrutiny of their practice by their own organisation. Others may seek outside, independent support. The briefing would aim to be supportive to practitioners and discuss support available
• Learning: To discuss the recommendations and learning from the case and any implications for practice

It is not appropriate to discuss operational issues in this meeting. The briefing will last no longer than 2 hours and cover the following areas:

• General issues relating to SCR's (as outlined in Working Together)
• The process of a SCR
• The issues specific to the case review (as outlined in the terms of reference)
• Clarification of any questions or queries that the practitioners may have.

Practitioner Briefings

These briefings would be available to a wider audience and use the material prepared in the case study (if available)

Aims:

• Clarification: to clarify and discuss the SCR process and its purposes
• Participation: to provide the opportunity to meet other professionals to discuss how agencies can best work together to safeguard and promote the welfare of children.
• Learning: To discuss the recommendations and learning from the case and any implications for practice

It is not appropriate to discuss operational issues in this meeting.

The briefing is usually facilitated by a member of the ESCRP; and the Training Development Implementation Sub Group. The briefing will last approximately 2 hours and cover the following areas:

• General issues relating to SCR's (as outlined in Working Together)
• The process of a SCR
• The issues specific to the case review (as outlined in the terms of reference)
• Clarification of any questions or queries that the practitioners may have.

5.5

Briefings for Managers

These briefings will use the overview report/case study and aim to offer:

• An opportunity for managers to discuss learning from the case
• Promote shared responsibility for practice development
• Build a culture of learning in organisations

Interface With Disciplinary

The purpose of this report, as distinct from any disciplinary action that an agency may take, needs to be carefully explained to staff. SCR's are not part of any disciplinary process, but information that emerges in the course of reviews may indicate that disciplinary action should be considered under the established procedures. Alternatively reviews may be conducted concurrently with disciplinary action, as in some cases, for example institutional abuse, disciplinary action may be needed to safeguard the welfare of other children.

Decision to hold SCR

• Add date when notification to Ofsted was made
• Add date when the Chair of LSCB (name and proof of independence) agreed to hold SCR
• State name and independence status of SCR Panel
• Provide detail as to why SCR was necessary using 8.5 or 8.6. as basis
• Identify  reasons for  any delays in deciding  to hold SCR

Key Issues:
(really important section)

• What specific issues or questions does this case raise?
• Are there any unusual factors in this case, what are they?
• Are there similarities with previous IMRs or SCRs, what are they?
• Are there any failings which appear obvious at this stage?
• Does there appear to be any gaps in multi -agency working?
• Are there any issues which relate to ethnicity, disability or faith which may have a bearing on this review? If not, say so.
• Is there any known research which may assist?

Expert Opinion

• Are there features of the case that indicate that any part of the review process should involve, or be conducted by, a party independent of the professionals/organisations who will be required to participate in the review?
• Might it help the Review Panel to bring in an outside expert at any stage, to shed light on crucial aspects of the case?

Time Period over which events should be reviewed

• Over what time period should events be reviewed, - i.e. how far back should enquiries cover, and what is the cut-off point?
• What is the relevance of selecting this time period?(Remember even  complex family history can be summarised)
• What family history/background information will help better to understand the recent past and present?

Organisations to be involved in this SCR
(would be useful to state which are universal/targeted/specialist services?)

• Which organisations and professionals will be asked to contribute to this review and submit reports or otherwise contribute?
• What action will the Board take if there is a failure to cooperate with this review?
• Who will make the link with relevant interests outside the main statutory organisations - e.g. independent professionals, independent schools, voluntary organisations?

Involvement of family members

• Are there any known factors which may affect the involvement of any family members?
• Which family members will be asked to contribute and why?
• Are there issues around timing which may affect this dialogue?
• Who will be responsible for supporting family members involved?
• What resources will be required to facilitate this process?

Other Parallel reviews
(e.g. PPO/ homicide or suicide reviews)

• Will the case give rise to other parallel investigations of practice - e.g. independent health investigations or multi-disciplinary suicide reviews, a homicide review where a parent has been murdered, a Youth Justice Board Serious Incident Review and a Prisons and Probation Ombudsman investigation where the child has died in a custodial setting?
• If so, how can a co-ordinated or jointly commissioned review process best address all the relevant questions that need to be asked, in the most economical way?
• What are the arrangements for co-ordinating and liasing with those involved?
• What problems may emerge in terms of confidentiality and sharing information and how will these be addressed?
• What are the implications of any different or challenging timescales?

Involvement of organisations in other LSCB areas

• Are there any other organisations involved with this family or any cross boundary issues which may involve other LSCBs?
• Who will take responsibility for contacting that LSCB to negotiate, manage and co-ordinate their involvement in the SCR process?
• What should be the respective roles and responsibilities of the different LSCBs with an interest?

Coroner's inquiries / criminal investigations

• Are timescales for Coroners/criminal or civil proceedings known and will revised timescales be likely?
• Who will liaise with the Coroner's office and/or Crown Prosecution Service?
• Has the Coroner issued any advice and how will this be addressed in the SCR?

Media coverage / enquiries

• How should any public, family and media interest be managed before, during and after the review?
• Be specific, including how reports will be anonymised
• Is there a communications/media strategy?
• How should any FOI requests relating this case be handled and by whom?

Legal advice

• Does the LSCB need to obtain independent legal advice regarding any aspect of the proposed review?
• If Yes, give reasons

SCR review timescales

• The review process should start within one month of notification and should, unless extensions are agreed, conclude and be forwarded to Ofsted within 6 months from that start date.
• What are the possibilities that these dates may change and why?

Commissioning of an independent overview author

• Which Author is being proposed and why? Indicate if they have any specific skills or knowledge.
• Specify in what way they are considered  'independent'
• Will LSCB require the Author to use a particular format for their report and is a template available?
• Specify what is expected of the Author and within what timescales, maybe give some examples of things to consider e.g., dates booked in to present the early findings to the panel, dates for final report to LSCB,  a link person for the author and the means by which their work will be facilitated.
• Clarify process should Board fail to ratify final report.