The LSCP Review Advisory Group (RAG) is responsible for identifying learning in relation to the most serious cases, including Serious Child Safeguarding Incidents (SCSIs), identifying good practice and areas of learning and improvement.
The fundamental purpose of reviewing incidents where children who have either died because of abuse or neglect, or where children have been seriously harmed, is to learn from those cases to help make improvements to systems that protect children and to prevent other children from being harmed.
A vital role or the group is to seek assurance related to actions taken following local learning activities, Rapid Reviews, Local Child Safeguarding Practice Reviews (CSPRs) or National Child Safeguarding Practice Reviews. This year has seen the introduction of a “live” online system for tracking, updating and gaining assurance regarding any actions and/or recommendations. Regular reports are provided to the RAG and the Executive in terms of progress, gaps and opportunities.
The RAG requests support from other LSCP sub-groups to disseminate learning, undertake quality assurance work to measure impact and to seek assurance that partner agencies use their own internal structures to implement recommendations.
The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel (the panel) and at a local level with the safeguarding partners.
Leeds has a robust review process in place which ensures that cases are considered in a timely manner in line with the requirements of the guidance, considers the views of the three safeguarding strategic partners and is overseen by a clear governance process, which is published on the website.
This year has also seen the development and implementation of a notification process between the LSCP, Leeds Safeguarding Adults Board and Safer Leeds. This is to ensure that any cases that the other safeguarding partnerships consider which could have the potential to meet the criteria for a review or relevant learning for the LSCP is notified to the LSCP in a timely way, and that there is a robust governance process to oversee the consideration of the case.
Notifications of SCSIs
The legislative framework of the Children Act 2004, places a duty on local authorities in England, to notify the Child Safeguarding Practice Review Panel (the ‘Panel’), of incidences of death or serious harm where it is known or suspected that a child has been abused or neglected. This includes those children that maybe temporarily outside the local authority’s area in which they usually reside.
Working Together to Safeguard Children 2023 states that the local authority performs this duty on behalf of the safeguarding partners. The local authority should notify the Panel of any incident that meets the above criteria via the Child Safeguarding Online Notification System. It should do so within five working days of becoming aware it has occurred.
In Leeds the LSCP has in place a process for discussing and agreeing those incidents which may meet the criteria for making a notification (the SCSI Notification Process). This process has oversight from its Executive and legal advice is provided, and in this reporting period all decisions have been unanimously agreed.
The local authority has a separate duty to notify the DfE and Ofsted when a looked after child dies, up to and including the age of 24 (in accordance with its leaving care duties). There is no automatic requirement for a local child safeguarding practice review, unless the criteria are met. However local partners may convene a local review if they think learning may be gained.
The LSCP RAG collectively considers whether an incident meets the criteria for a SCSI notification, with the relevant partner agencies providing information and professional opinions to support the decision making. Following the notification of a SCSI by the local authority to the National Safeguarding Panel the LSCP through the LSCP RAG will promptly undertake a Rapid Review.
Cases for consideration are raised to the RAG via partner agencies using the SCSI notification and discussion form.
When an agency other than the local authority becomes aware of an incident that appears to meet the criteria for notification, the relevant partners discuss this with their agency’s safeguarding lead (or RAG member) and if appropriate refers this to the LSCP RAG for a discussion in relation to a potential notification.
In 2024-25 the RAG considered five cases for possible notification. The decision was made that three of these cases did not meet the criteria for notification and feedback was given to the partner agency who raised the concern and the rationale for the decision made.
Rapid Reviews
A Rapid Review is a multi-agency process which considers the circumstances of a SCSI. The purpose of the Rapid Review is to identify and act upon immediate learning and consider if there is additional learning which could be identified through a wider Child Safeguarding Practice Review (CSPR).
The Rapid Review enables safeguarding partners to:
- 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 and share any learning appropriately
- identify immediate learning and consider the potential for identifying improvements to safeguard and promote the welfare of children
- decide what steps they should take next, including whether to undertake a local Child Safeguarding Practice Review
Once the Rapid Review responses have been received, RAG members meet, alongside the Rapid Review individual report authors, to consider the information, key learning points and areas for further consideration. This allows authors to share their information in a responsive way and ensure that the process is not remote. RAG members then meet separately to consider if the criteria to undertake a review is met.
Minutes of all meetings are produced alongside the Rapid Review form, capturing the rationale for any recommendations made and shared with the LSCP Executive, who make the final decision, prior to submission to the National Panel.
In 2024-25, two Rapid Reviews were completed and sent to the National Panel. In both cases it was felt that the learning had been gathered and responded to within the Rapid Review process and the RAG and subsequently the Executive recommended not to take these cases forward for a CSPR, with the National Panel agreeing with these decisions. These reflected the work led by the RAG to improve focus on analysis in agency considerations and this has in turn enabled speedier learning of lessons and implementation of action plans.
CSPRs
In 2024-25, three CSPRs concluded. It was agreed that two of the cases would not be published in full, due to the potential impact upon other children and family members. The National Panel are also notified of these decisions and can ask for LSCP’s to reconsider. On both these CSPR’s the National Panel agreed with the decision not to publish. The learning from the reviews is published and disseminated widely and considered within other sub-groups. One of these is already available on the LSCP website and the learning from the subsequent case will be published early in 2025-26 as it only reached sign-off stage and feedback from the National Panel late in 2024-25.
It has been agreed that one CSPR report will be published in full, and this will be available early in 2025-26 via the LSCP website.
There are currently three CSPRs yet to be completed, with progress overseen by the RAG and regular updates received by the LSCP Executive.