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National SCR’s from January 2017 to June 2017

A serious case review (SCR) takes place after a child dies or is seriously injured and abuse or neglect is thought to be involved. It looks at lessons that can help prevent similar incidents from happening in the future.

Please find below a briefing paper on National SCR’s from January 2017 to June 2017.

National SCR’s


Child Sexual Exploitation – Lessons Learned Briefing Paper, June 2017

Dudley Safeguarding Children Board (DSCB) has a duty to evaluate multi-agency working through case file audits which involves professionals from across the children’s workforce. These audits are often referred to as MACFAs (multi-agency case file audits).

The purpose of MACFAs undertaken on behalf of the Board is to quality assure the local systems and services in place for children, to assess how effectively all agencies engage and work in partnership with children and families, and in turn, share the learning regarding the quality of practice and lessons for improvements.

A MACFA took place on the 13th June 2017 which focused on Dudley approach and response to issues of Child Sexual Exploitation (CSE).

The briefing paper below informs how changes can be made to professional practice across the children’s workforce to ensure Dudley’s response and support to issues of CSE are effective and robust.

CSE Lessons Learned Briefing Paper


Briefing: Location (map) settings in apps

Many apps such as snapchat, facebook and twitter use location services – a setting which can let people know where you are when you are logged in or when you post something (depending on your settings). Many of them have safety features that can turn this setting off and so restrict who can see a user's location, however if these settings are turned on the app may show your location on a map increasing the possibility of unwanted contact from strangers in your location or even enabling someone to follow you without your knowledge.

It is essential to learn about the location settings on the apps that you use and regularly check that the settings are at the level you want them to be so that you have control over who can see your location – this is particularly important for children and young people.

Please see the briefing below for more information and helpful hints and tips.

Location settings in apps


Producer of Chatback productions picks up prestigious mayoral award

The Mayor’s Civic Awards celebrate the achievements of those people who work tirelessly in the borough to make it a great place to live, work and visit.  Many people achieve great things or dedicate their time to helping others.  Much of this work goes unnoticed, but through Dudley Council’s annual Mayor’s Civic Awards their achievements are recognised and celebrated.

The Frank Foley award for community spirit, sponsored by Sanders and Co Solicitors, was awarded to Jane Ahmed (pictured above), who set up the Chatback group for 11-18 year-olds from foster families. 

The young people are either in care or are birth children of foster carers who want to support other young people in the looked after system. The organisation have produced a wealth of powerful films about being in care, the relationship with birth families, domestic abuse and their most recent production, ‘Anybody’s Child’ which is about child sexual exploitation.

Starring the young people alongside comedian and actress Josie Lawrence, the film aims to help people understand how easily exploitation can happen and to recognise the warning signs so they can stay safe and make the right choices.

People are being encouraged to watch ‘Anybody’s Child’, which tells the story of a young girl who is groomed by a boy she trusts and who she believes loves her. The film will feature on the regional See Me Hear Me campaign website www.seeme-hearme.org.uk

For action and information:

Incident involving consumption of jelly cubes – Coroner’s Inquest

This letter is for information and action as deemed appropriate and is relevant to officers who engage with operators of child care establishments as part of their routine work.

Following a Coroner’s inquest into the death of a child in a nursery where raw jelly cubes were being used as part of sensory play, the Coroner requested that Ofsted highlight the risks associated with this practice to relevant childcare establishments. Ofsted highlighted the issue in their February Newsletter to Directors of Children’s Services drawing their attention to the risks to young children, especially where this was not closely supervised.

The FSA agreed to separately forward this information to Local Authority Environmental Health Services to similarly highlight the issue so that officers are aware of the risks and are able to take the issue into account during any relevant inspections or contact with such establishments

I have attached the Ofsted DCS update. The relevant information is the fifth article which I have reproduced below:

Findings of a recent Coroner’s inquest

Ofsted would like to draw to the attention of Directors of Children’s Services the findings of a recent Coroner’s inquest into the death of a child in a nursery where raw jelly cubes were used as part of sensory play, during a free-flow arrangement within the nursery. In particular, the inquest identified the risk to young children of choking on raw jelly cubes, especially in circumstances where they are not closely supervised. The Coroner has issued a report to prevent future deaths addressed to Ofsted, the Local Government Association and the Food Standards Agency, asking them to raise awareness of these potential risks. Under the Childcare Act 2006, local authorities have a statutory duty to provide information, advice and training to early years and childcare settings. Local authority staff who are advising settings under this statutory duty may therefore wish to take into account the findings of this inquest in delivering their advice.

For more information about the inquest, please contact Westminster Coroner’s Court. It is anticipated that details of the report to prevent future deaths will be made available on the Courts and Tribunals Judiciary website in due course. 

John Barnes, Head, Local Delivery Division,Food Standards Agency

Feedback from ME Festival

See attached document at the bottom of this page.


Research report: A study to investigate the barriers to learning from serious case reviews

A number of reports have drawn attention to the fact that lessons learned through the serious case review process are not finding their way into changes in practice. A research team from Kingston University was commissioned by the Department for Education to investigate barriers to learning from serious case reviews (SCRs). They wanted to identify ways of overcoming these barriers, and ways to ensure any learning was taken forward and embedded into policy development and practice.

Between May and July 2013, the research team gained the opinions of  68 independent chairs of local safeguarding children boards and ran focus groups with 78 professionals from a range of disciplines, as well as undertaking a review of current literature and research.

The survey of independent chairs found they suspected that  learning from serious case reviews took place at a local rather than a national level, with  41 % stating that they felt a good deal of learning took place locally and  only 5.8% considering that learning occurred nationally. In the focus groups, 38.4 %of participants acknowledged SCRs helped improve child protection policy and practice a little, and 33.4 % said they helped a lot. Only two per cent thought they did not help much.

The study found barriers cited by independent board chairs which included:

  • There is currently a  blame rather than a learning culture

  • Professional, organisational and cultural resistance to learning e.g. the idea that  "it couldn't happen here";

  • Attention to learning can be skewed and determined by national media selectivity and coverage.

  • The numbers of recommendations that generate new policies and procedures being overwhelming

  • The SCR process being too costly in terms of finance and capacity and also being repetitive which may not generate the most useable or interpretable learning for local practice.

  • Front-line staff have limited involvement in the generation of learning and ensuring its relevance and applicability.

  • Findings from SCRs were often inaccessible to professionals across different sectors due to a lack of common language to make them meaningful and manageable to all users across different sectors, professions and agencies.

The majority of respondents said learning from serious case reviews would be made easier by a process that would help to collate, analyse and disseminate lessons learned nationally, with a focus on context so learning could be considered against local demographics and  circumstances. They stated that lessons should be made explicit, practicable and relevant to frontline practice and practitioners.

The report sets out good practice in eight key areas.

Good communication strategies eg.
  • Wide distribution of summaries of key issues to practitioners

  • Targeted training 

  • Using a learning model to undertake SCR’s

  • Ensuring that the LSCB receives regular updates about progress from the SCR

Securing quality through QA activity / action planning eg.
  • Seminars, workshops and campaigns/newsletters with follow up audit and QA activity

  • A robust QA framework of auditing cases involving practitioner

  • Ensuring that reviews are primarily about learning and quality improvement, rather than as an accountability mechanism

  • Clear action plans which are kept under review.

Sharing learning in the context of partnerships and multi-agency work eg.
  • Proactive learning events

  • A committed Board Business unit which works well and is well staffed and supported by the agencies

  • SCR sub groups of the LSCB are an important vehicle for disseminating and discussing learning across agencies

  • Integrate the focus on the child and its journey with the core functions of the Board to ensure joined up and coherent joint working

Developing a culture of learning with front-line practitioners locally eg.
  • A culture of continuous learning and development and people are given the time and space to reflect on practice and how the learning from SCRs can inform their own work

  • Collective ownership of the issues and an individual responsibility to implement the outcomes

  • Local initiatives arising from local or very high profile cases.

  • Completion of individual agency reviews to promote a culture of local reflection and learning

Avoiding blame
  • Undertaking the SCR in as supportive a manner as possible

  • Using a systems based approach

  • The learning from one case with a tragic outcome isn't seen as a proxy for the health of the whole system

  • Strong ownership by all the agencies to implement recommendations and sign off all the actions

Publication processes
  • Making it clear that there is an expectation that SCRs will be disseminated.

  • Having an independent author with time!

  • Strategic leads to be involved in writing

  • Very difficult to compare findings which are expressed so differently - which is why the bi-annual review is so useful

Strengthening relationships
  • Strengthening relationships which focus on honesty, transparency and a willingness to learn to improve

  • Reflective and challenging supervision model in which the actions and reactions of professional staff are scrutinised

  • Highlighting a few points from the findings and using the LSCB to highlight them through newsletters, attendance at meetings and the work of the sub-committees

  • Front line managers get the key messages, they are able to incorporate into their supervision practice

Implications for practice

The researchers make a number of recommendations as to how their findings could impact on practice. They suggest the appropriateness of SCRs as a learning tool should be reviewed, and call for the establishment of a national database of review summaries under key themes, as well as the dissemination of regular themed reports. They recommend inspections should assess the impact of serious case reviews on practice and details of learning, and practice changes, following SCRs should be captured in local and national reporting structures.


:: The full ME Festival feedback report was compiled by Healthwatch Dudley with Dudley CCG to capture and share the energy, enthusiasm and passion of young people’s voices and is available to download at the bottom of this page.

Use of images: guidance update version 6 (Dec 2014)

Dudley Safeguarding Children Board Use of images guidance has been updated to take into account and address safeguarding concerns.  Version 6 is now on the website including updated consent forms.

Updates at a glance

2.5 Additional advice regarding images captured by a third party

2.6 Additional guidance re the ramifications of capturing images without consent

3.8 Additional guidance on capturing images at large events

3.9 Additional guidance on the use of images on websites and newsletters

3.13 New guidance on inappropriate use of images due to the rise in referrals both by adults and children.

Appendices – Consent forms have some minor changes

:: link to use of images guidance

Anti-bullying pledge scheme

A special edition of the Dudley Schools Anti-Bullying Pledge Scheme newsletter is now available as a download at the bottom of this page.