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1.3.6 Case Review Protocol


This chapter provides guidance as to how a case within Children’s Services can be reviewed, when the case meets the criteria for concern; or where a case has progressed well. For information on the review of the child’s record, please refer to the Quality Audit Procedure.

This chapter was introduced to this manual in June 2013.


  1. Introduction
  2. Criteria for using the Case Review Protocol
  3. Purpose of the Case Review
  4. Case Review Process
  5. Case Review Meeting
  6. Case Review Learning Points

    Appendix 1: Reflective Tool for Practice

    Appendix 2: Flowchart Case Review Protocol

1. Introduction

Where a case gives rise for concern, or where it is felt that a case has progressed well, this protocol sets out the way in which the activities of children’s services can be reviewed.

Please note that this protocol provides guidance and is permissive. Case reviewers should amend as per any scoping document requirements, or to fit in with the circumstances of the situation under review.

2. Criteria for using the Case Review Protocol

Criteria for ‘Concern’

Means that a case has come to senior manager’s attention, examples might be:

  • The death or serious injury of a child (in care, with a Child Protection Plan, a Child in Need, a child with a TAC Plan, or a child unknown previously to services) where abuse or deliberate injury is suspected to be the cause.

    NB All Staff should be aware of possibilities for cases to move into serious case reviews under the auspices of Lincolnshire Safeguarding Children Board, and as per “Working Together” which may negate usage of this protocol. Further information on Serious Case Reviews can be found in the Lincolnshire SCB Policy and Procedures Manual and on the Lincolnshire SCB website. Staff should be aware or made aware that material collected as part of any case review will be made available to any Serious Case Review which takes place on the case.

    Staff should also be made aware that in the event clear evidence or allegations of misconduct arise within a review, such matters will be dealt with through investigation, following existing processes;
  • Major failure (perceived or evidenced) of single or interagency working;
  • Incident likely to generate media interest;
  • An investigation into a complaint has highlighted specific issues of unsatisfactory practice;
  • This protocol should be cross referenced with “Briefing Notes for Assistant Directors - Significant Incidents”. (available on George).

Criteria for ‘Progressing Well’

Means that case activity has produced a successful and positive outcome for a child and this appears to evidence excellent practice from local authority staff, excellent multi agency practice, or as a result of the actions of a member of staff or set of staff.

3. Purpose of the Case Review

The purpose of the case review is to identify learning points, to assist in the refresh or amendments to practice or procedures within the service, or to reinforce good practice by demonstrating and sharing real successes. It is also to look at elements of practice to identify areas which could have been completed to a higher standard, both to assist in further training and development for individuals, or to put in place across the board different and better ways of ensuring work is completed to a higher standard.

A case review is to assist all directorate staff and managers to understand the work done with and for children and their families, with a constant agenda to find better ways of working, and to become excellent in service delivery.

On completion of the Review the commissioning Assistant Director has responsibility for sharing the learning points with Training and Development Team, who in turn can build learning intro training events, either as part of general refresh of training or by setting up specific learning events.

4. Case Review Process

Once a case of concern, or a case which has progressed well has been identified, (which can be from any member of staff or manager), then the matter should be brought to the attention of the Assistant Director - generally through a written briefing.

Assistant Directors may request use of this protocol following discussion with and agreement of The Director of Children’s Services, however this is discretionary as Assistant Directors can also request the manager of the case to review the circumstances and make appropriate and timely amendments to the actions in the case.

A lead reviewer (who can have had no direct involvement of line management of the specific case) is appointed, and meets with the Assistant Director who commissions the piece of work and agrees an outline scope. The Assistant Director should provide a written brief description of what the concerns are, or why the case has been seen as good practice, and a list of preliminary questions or areas for exploration are agreed.

Lead Reviewers can be Team Managers, Heads of Service or Assistant Directors. It is the decision of the commissioning Assistant Director to appoint according to the needs of the review.

The Lead Reviewer begins the review by:

  • Reading and reviewing any available MOSAIC records, and or manual records in relation to the matter in hand;
  • Reading any relevant policies and procedures, both within Children’s Services and within the Lincolnshire Safeguarding Children Board manual of policies and procedures;
  • At any point where the reviewer identifies different or new issues, he or she should feedback to the commissioner and agree if additional inclusions to the review are required;
  • The Lead Reviewer may ask for the support of other managers or staff in understanding areas of work with which the Lead Reviewer is not sufficiently familiar. The Lead Reviewer will decide the input of any assistants in this regard;
  • Upon appointment the Lead Reviewer should explore with the commissioning Assistant Director any training needs, and the Assistant Director should seek to ensure the Lead Reviewer is provided with support or mentoring as needed.

The Lead Reviewer arranges to meet with the group of local authority staff jointly as soon as practically possible, including a note taker. There can be individual meetings with members of staff where this appears sensible; however the Lead Reviewer should recognise the potential sensitivity of the meeting and ensure the individual member of staff is invited to bring a supervisor or supporter to the meeting. Notes are taken, and a copy of these should be provided to the member of staff following the meeting. The Interviewee and interviewer should sign the notes as an agreed record of any meeting.

Staff are reminded (or needed to be reminded by the lead reviewer) that notes of meetings will be made available to authors if independent management reviews - if LSCB commission a Serious Case Review.

5. Case Review Meeting

Where possible, the Lead Reviewer will meet with all staff connected with the case (from Children’s Services) to assist in understanding and learning. The timing of this meeting may depend upon any parallel processes, such as Serious Case Reviews, Criminal Proceedings, Care Proceedings etc. A judgement needs to be made regarding timing and the lead reviewer may seek the advice of the commissioning Assistant Director.

The Lead Reviewer sets out the reason for the meeting, and shares the scope of the enquiries.

Each participant is invited to explain his or her role in the case, his or her responsibilities, and to talk about things they felt worked well with and for the family, and things that they did not feel went well with and for the family. (This in all cases, so that strengths and areas for development can be considered equally). This section of the review should be based on the principles and aspects of reflective practice. Please refer to Appendix 1: Reflective Tool for Practice for reference.

The Lead Reviewer then facilitates an open discussion with all the participants on the work with the family. This section of the meeting should also focus on how participants experienced the case; their perceptions and feelings, and how they reached various views or decisions. This section of the review should be based on the principles and aspects of reflective practice. Please refer to Appendix 1: Reflective Tool for Practice for reference.

The Lead Reviewer then asks the group to focus on:

  • The worries which were identified as part of the scoping of the case and asks for views on these issues, and or the things which went particularly well;
  • What they feel may or could or should have been done differently;
  • What they feel they did well and would want to do again;
  • What the feel they have learnt from this review;
  • What recommendations they would wish to make for the future.

The Lead Reviewer closes the meeting, describing the next steps which will be:

  1. A written review of the case, describes the worries identified, the aspects which went well, what could or should have been differently, and an analysis of the way in which the case had moved forward;
  2. Attached to the written review will be a set of relevant recommendations to amend practice;
  3. The Assistant Director to agree if and how the draft written review is distributed to all participants to comment on;
  4. The draft is finalised and will be presented to an Assistant Director;
  5. The Assistant Director is requested to decide on presentation at DMT, and to agree to take responsibility for the follow up of any agreed recommendations;
  6. The Assistant Director is requested to decide if and how final report is released to participants, giving thought to the need for redaction, anonymisation and/or whether a debriefing session is required with staff;
  7. The Assistant Director is requested to write to the participants of the review and the Lead Reviewer thanking them for their participation in the review, and telling them what is agreed for further action.

A flowchart of the Case Review Process can be viewed in Appendix 2: Flowchart Case Review Protocol.

6. Case Review Learning Points

This process describes an internal review, however the Lead Review and Commissioning Assistant Director should at all times give consideration to the way in which family members can or should be involved in discussions, and to better inform the review from a service user’s perspective.

Learning Points should be formally shared with Learning and Development staff to better inform future learning. Consideration can be given to using the case material suitably anonymised in training situations.

If during the course of a review an aspect of staff actions or behaviour gives rise to a question that a disciplinary or capability issue has emerged, then the Lead Reviewer should immediately discuss with the commissioning Assistant Director. This may affect the progress of the case review, or may run alongside.

If during the course of the Review the Lead Reviewer becomes aware of immediate safeguarding concerns or practice issues, these must be dealt with using normal referral systems, in addition to advising the Assistant Director without delay.

Appendix 1: Reflective Tool for Practice

Click here to view Reflective Tool for Practice

Appendix 2: Flowchart Case Review Protocol

Click here to view Flowchart Case Review Protocol.