Learning and Improvement Framework (LIF)

The following principles outline the outcomes Liverpool LSCP and partner agencies should achieve through the process of conducting case reviews, practitioner forums and audits. These outcomes will be placed in the context that any system, including safeguarding systems can only manage and reduce risk, not eliminate it and that systems are made up of numerous variables that constantly change and fully appraising and managing risks of each variable is a complex task.

• There should be a culture of continuous learning and improvement across organisations, identifying opportunities to draw on what works and promote good and effective multi-agency practice;
• Learning and reviewing methods recognise the complex circumstances in which professionals work together to safeguard children – as much effort in the process of reviewing should go into identifying and analysing areas of good practice as well as practice that requires improvement;
• Learning and reviewing methods are transparent in the way they collate and analyse data and make use of research and evidence to inform findings;
• The approach taken to learning and reviewing should be proportionate to the scale and complexity of the issues being examined;
• Professionals must be involved in learning and reviewing opportunities; contributing their perspectives without a fear of being blamed for actions taken in good faith;
• Families, including children (where possible) should be invited to contribute in learning and reviewing opportunities; there should be clarity of how they will be involved and their expectations should be managed appropriately and sensitively;
• Serious Case Reviews should be led by one or more persons who are independent of the case being reviewed and the organisations whose actions are being reviewed;
• There is transparency with professionals, family and the public in disseminating the learning; final Serious Case Review reports will be published and findings from all other reviews, practitioner forums and audits will be summarised in LSCP annual reports.

Regulation 5 (1)(e) and (2) of the Local Safeguarding Children Partnerships Regulations 2006 sets out an LSCP'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:

1. Abuse or neglect of a child is known or suspected; and
2. Either —
   1. The child has died; or
   2. 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” in the context described below and regulation 5(2)(b)(ii) above 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. LSCPs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

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 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.

The LSCP CIG group, comprising of senior managers from partner agencies, has responsibility for considering cases referred to them. Primary responsibility of the group is to rigorously review agencies' contact and interventions with a child and family and consider as to whether a case satisfies the statutory criteria for initiation of a Serious Case Review.

The Critical Incident Group (CIG) meets on a monthly basis to review cases referred to them for consideration. A request to agencies for further information will have been made by the LSCP Administrator in advance of this meeting.

Following consideration of information from each of the partnership agencies, or their representative, the Chair of the CIG advises the independent Chair of LSCP, as to the group's recommendations; to initiate a Serious Case Review (SCR); to initiate another review (see Appendix 5: Learning and Improvement Framework – Activities), or undertake specific multi / single agency-actions. The final decision to initiate a SCR rests with the independent chair of LSCP.

The Independent Chair of the LSCP confirms, in writing, his/her decision as to whether a serious case, or other review, should be initiated. Immediately following the decision being made, the LSCP notifies Ofsted as to the decision of the independent chair.

Decisions on whether to initiate a Serious Case Review will be made within one month of the LSCP being notified of the incident triggering the threshold.

Local Safeguarding Children Partnership is responsible for ensuring that a review of each death, of a child normally resident in the LSCP's area, is undertaken by a Child Death Overview Panel.

Merseyside Child Death Overview Panel (CDOP) involves all five Merseyside LSCPs; Knowsley, Liverpool, St. Helens, Sefton and Wirral. Merseyside CDOP analyses any deaths occurring in children, aged from new born up to eighteen years old, and identifies any modifiable factors that could highlight areas for future improvement. Merseyside CDOP is responsible for reviewing deaths from the larger population across Merseyside in order to ensure it is better able to identify significant recurrent contributory factors.

Merseyside CDOP a core membership drawn from organisations represented on the LSCP with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. Merseyside CDOP also includes a professional from public health as well as child health.

In reviewing the death of each child, the CDOP will consider modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.

Merseyside CDOP is responsible for:

1. Collecting and analysing information about each death with a view to identifying:
   1. Any case giving rise to the need for a review mentioned in regulation 5(1)(e);
   2. Any matters of concern affecting the safety and welfare of children in the area of the authority;
   3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
2. Putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death (Working Together to Safeguard Children, Ch 5).

Liverpool SCB are committed to regularly conducting a range of reviews, not only on cases which meet statutory criteria (Working Together to Safeguard Children), but also on other cases which can provide useful insights into the way organisations are working together to safeguard, promote and protect the welfare of children.

Any additional Learning and Improvement activity will be informed from a range of other sources including learning from other significant national inquiries and reviews, from national and local research findings and from listening to the voice of local front line practitioners, from children, young people and their families.

The LSCP will also include request from organisations / staff / managers details of cases where Multi Agency working produced improved or good outcomes.

Table 1 details the range learning methodologies utilised by Liverpool LSCP.

Click here to view Appendix 5: Learning and Improvement Framework – Activities.

This framework will apply to Liverpool LSCP and all partner agencies in their delivery of workforce development activities. It should also inform single agency frameworks to ensure connectivity and compatibility. It is also therefore essential that the members of LSCP Professional Development Committee reflect the wide range of both statutory and non-statutory bodies, partner organisations and other key agencies within the Adults, Children and Families workforce.

Membership is made up of those multi - agency professionals who act as key leads for Workforce Development within their agency or who have a role in supporting learning and improvement within their agency. It may also be appropriate to co-opt further members onto this group as appropriate for short fixed periods of time to complete actions required to disseminate local learning following a specific review.

The learning and recommendations identified following review can be implemented in a number of ways, such as improved procedures and policies, supported through training programmes and in other relevant learning activities. In some cases it will be incumbent on individual agencies to consider how these recommendations can best be implemented and in turn provide assurance to the LSCP that this has been achieved effectively.

Members of the Critical Incident Group will be accountable for ensuring that actions for their agency have been completed and for ensuring that identified learning has been effectively disseminated within their agency. This will be completed in conjunction with the LSCP Professional Development Committee.

Completed action plans will be reviewed and the impact measures collated at the scheduled biannual meetings.

Key messages identified at review will also be integrated within LSCP Multi Agency Level 1 and Level 2 Training. Further training needs may also be identified.

Click here to view LSCP Review - Learning and Improvement - Process Flowchart.

Appendix 1: Learning and Improvement Index

Appendix 2: LSCP Critical Incident Group Process - Flowchart

Appendix 3: LSCP Process: Responding to Cases that May Warrant the Undertaking of a Serious Case Review

Appendix 4: LSCP Serious Case Review: Request for CIG Consideration Form (CIGSCR1)

Appendix 5: Learning and Improvement Framework – Activities