Serious Incidents

1
Serious Incidents SCRCommon Solutions for
Management Monitoring

• Briony Ladbury Safeguarding Lead NHS London
• Rachael Horner NHS London
• Samantha Gradwell NPSA

2
Personal Observations

• Local Health Authorities 1996
• Few Case Reviews
• Review of Records, Defensive
• No staff or parental involvement,
• No feedback audit of recommendations
• PCTs St HA 2002
• Complicated and un-standardised, more open
• Some parental involvement
• Exec summaries distributed, learning poorly
  disseminated
• Unrealistic / nonevent recommendations
• Weak implementation and audit
• PCTs NHS London (SHA) 2006
• More reviews undertaken!
• Use of SUI structured investigation techniques
• Root causes identified
• SMART recommendations
• Implementation Monitoring at many levels

3

• Key Findings of
• Local Safeguarding Children Boards A
  Review of Progress

Every Child Matters
Change For Children
Dec 2006
4
Specific Findings in Report

• Serious Case Reviews
• Different approaches - inconsistency
• Capacity and resource implications
• Timing varied
• Implementing recommendations variable
• Confusion in relationships between SCRs, Child
  Death, DV Homicide Reviews and SUI processes
• Wish for common structures, templates etc
• Better dissemination of findings

5
Next Steps DfES Report

• SCRs to be priority
• Need for templates protocols etc
• Better engagement of SHAs (sec 11)
• BUT
• SHAs are relatively new organisations working
  out their own systems to underpin their
  responsibilities

Recommendations DfES Report
6
NHS London where does it fit?

• NHS London is responsible for ensuring that the
  capital's health services deliver world-class
  care
• developing and implementing strategy for health
  and healthcare in London
• holding local organisations to account for the
  quality of the care which they provide
• ensuring capacity through the development of the
  workforce, technology and buildings.
• NHS London is member of London Safeguarding Board
• Functions as LSCB partner
• Supports and advise Board
• Supports Practice
• Monitors Quality and provide feedback

7
SUI / SCR interface

• Highly Complex!
• Factoring in
• SCR Process Ch 8
• SCR (not Ch 8)
• Single Agency IMR
• DV Homicide Reviews
• Youth Justice Board Enquiries
• ALSO
• GOL OFSTED alliance
• LSCB recommendations
• Child Death Review
• CG at Local / London level
• RCA principles (NPSA)

8
Priorities for NHS London

• NHS London committed to safeguarding
• Keen to support practice
• Promote standardised processes
• Templates, guidance, report formats, timescales
• Holding Trusts to account
• requires explicit and consistent expectations
• Support the London Safeguarding Board
• Disseminate learning
• Maintain quality improvement

9
Where are we now?

• SUI reporting New system
• Clinical Governance Systems
• Risk Managers unsure of SCR process
• where they fit
• How they interface with Designated/Named
  Professionals
• SHA, LSCB, GOL Ofsted - Ch 8 tracking

THE DILEMMA THE REALITY
10
Serious Case Reviews

• Need to utilise RCA principles

Links to Risk Management Governance Systems Be
fit for purpose in a multi-agency context
11
Next steps

• Draw on experience in the field
• listen to those who do
• What are the similarities?
• What are the differences?
• How do we ensure the various approaches come
  together to influence practice?
• Embrace and promote evidence based change
• National and LSCB reports/recommendations for SCR
  
• Adopting RCA principles workforce development
• Promote a culture of openness and challenge
  consider process to manage difference as new
  systems embed
• Improve services for families

12
End