Aligning Serious Case Reviews and Serious Untoward Incidents

1
Aligning Serious Case Reviews and Serious
Untoward Incidents

• Jan Pearson, Associate Director for Safeguarding
  Children and
• Eirlys Evans, Associate Director for Assurance
• East London NHS Foundation Trust
• London Mini-Conference February 2008

2
Trust Incident Policy has Responded to
Independent Recommendations

• The Trust should review its SUI process including
  how it links with the LSCB SCR process, creating
  clear lines of accountability, policy, procedures
  and guidelines for panel members, staff and the
  public. Specialist note takers should assist them
  in the process.
• The Trust should take steps to conform with your
  policy that follows any serious incident, those
  involved in both the incident and its management
  should be thoroughly debriefed and any lessons
  should be widely disseminated.

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Level 1a investigation
SUIs / SCRs
SUIs affecting children or parents
SUIs
Level 1a or Level 1b investigation
Clinical Reviews affecting children or parents
Clinical Reviews
Level 2 investigation
Incidents reported not involving
children/parents/ pregnant women No further action
All incidents involving children/parents/
pregnant women Brief follow-up by SCT
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Summary of Trust Incident Process

• Electronic reporting form on Datix used by all
  services
• Completed form sent to Assurance Dept
  electronically
• - Within 2 hours for a potential SUI
• - Within 24 hours for all other incidents
• Incidents with children/parent boxes ticked
  forwarded automatically to Safeguarding Children
  Team (SCT) (see later slide) - SUI Coordinator
  alerts SCT to the most serious and staff may have
  also alerted SCT
• SUI Co-ordinator informs NHS London and relevant
  PCT of potential SUIs
• Service must provide a 72 hour report for
  potential SUIs

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Level of Investigations

• Level of investigation determined by Medical
  Director/Head of Nursing if implications for
  children may be discussed with SCT
• Level 1a or 1b (graded 8-25) are SUIs and are
  reported to NHS London
• Level 2 (graded 2-7) clinical or
  incident/non-clinical review
• Level 1a is SCR level so SUI report is also an
  IMR
• Level 1a panels determined by Medical
  Director/Head of Nursing
• Level 1b Borough Director commissions
  investigators from outside the service area
• Level 2 Borough Director allocates one or more
  local investigators
• SCT could be involved in investigations at all
  levels

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Excerpt from Incident Form
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The Safeguarding Children Team (SCT)

• Full time Associate Director for Safeguarding
  Children
• 3 full time Named Nurses/Professionals one in
  each borough
• - City and Hackney
• - Newham
• - Tower Hamlets
• 3 sessional Named Doctors (all CAMHS) one per
  borough

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Role of Safeguarding Children Team

• Follow up all incidents where relevant boxes are
  ticked
• Send brief findings to SUI Co-ordinator and NFA
  or use info for further investigation
• Sit on all Level 1a SUI panels which are also SCR
  IMRs
• Involve Childrens Social Care/LSCB rep on panel
  if appropriate
• Co-investigate Level 1b SUIs if significant
  issues re children
• Co-investigate or offer advice for Level 2
  Clinical Reviews if significant issues re
  children
• Often prepare chronology
• Often write IMR/SUI Report
• Sit on LSCB SCR Panel
• Liaise with key Trust personnel in Assurance,
  Legal, Corporate, Communications etc
• Liaise between Trust and LSCB
• Provide feedback from LSCB for NHS London if
  required

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Timescale Issues for Level 1 SUIs/IMRs

• 72 hour report to NHS London written by service
• 60 working days (ie 12 weeks or 3 months) for
  final IMR/SUI Report
• Allocating panel members should happen within 2
  weeks of incident
• Convening panel after that can cause delay
• Aligning timeframe with LSCB deadlines
• Report has to go to Trust Board before released
  to LSCB

10
Written Report Issues

• 3 LSCB and 1 Trust format for chronology/report/ac
  tion plan
• Enabling report to serve two purposes
• Font
• Date style
• Word or excel spreadsheet
• Turn final report from word into pdf so it cannot
  be changed

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IMR Investigation Process

• Look at case files only or interview staff?
• Panel or one investigator only?
• Contacting family direct or via police family
  liaison officers
• If and when interview family members?
• Providing ongoing information about process to
  staff and family
• Do staff have access to the case notes before and
  at interview?
• Do staff prepare a written statement for panel?
• Are staff given a copy of the chronology for
  clarification at interview?
• Are interviews minuted?
• Are minutes shared with interviewees for
  correcting?
• Should panel meet with clinical teams as well as
  interview individuals?
• Is draft report shared with interviewees
  individually or as a group for accuracy/tone?
• Is the report emailed or copy given out and taken
  back in on day?

12
LSCB Process

• Planning at outset crucial
• Clarity of tasks/decisions at LSCB SCR Panel
  meetings
• Opportunity for individual agencies to discuss
  their reports with overview authors?
• Timescales for releasing IMR to LSCB

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Report Recommendations

• Making them SMART so services can implement an
  Action Plan
• Should all IMR/SUI recommendations be
  incorporated into the SCR Overview report?
• Ensuring Trust has a system for monitoring
  internal and external recommendations

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Action Plans

• Service should draw up action plan to respond to
  recommendations some are service specific some
  are corporate
• Service and SCT provides progress reports
• AP Progress Report monitored by Borough Clinical
  Governance Committee and Trust Safeguarding
  Children Committee
• SCT takes progress report to LSCB SCR Committee
  for sign off
• Some PCTs also monitor at inter health trust
  Safeguarding Children Strategy Group

15
External Monitoring

• If PCT reports an SCR incident to NHS London on
  behalf of all local health trusts how to ensure
  own Trust has it logged in own system is the
  fact of doing an SCR the incident to be reported?
• Closed cases are not covered by our SUI policy so
  technically LSCB needs to formally request Trust
  involvement in SCR
• NHS London receives Trusts IMR/SUI Report and
  Chronology who should send them the SCR
  Overview report?