National guidance for child protection committees undertaking learning reviews

Guidance to support child protection committees to reflect, learn and improve child protection systems and practice when a child or young person dies, is significantly harmed, or was at risk of death or significant harm or where effective practice has prevented harm or risk of harm.

3. Initiation of a Learning Review: The Decision-Making Process

Child Protection Committees should have in place mechanisms for deciding whether or not to initiate a Learning Review. The decision-making process should embody the key features of proportionality and timeliness.

Any member of the Child Protection Committee, agency or practitioner can raise a concern about a case which it is believed meets the criteria for a Learning Review and submit a notification to the CPC (a link to a notification form template is at Annex 1.1). On receipt of this notification the nominated person or sub-group within the CPC should request further information from agencies involved with the child and family or who may support the understanding of the situation (a link to a template is at Annex 1.2). The purpose of information gathering at this stage is to make a decision about whether or not to proceed with a Learning Review with reference to the criteria as specified in the previous section and therefore the data gathered should be only enough to make that decision. It will include a brief account of agency involvement prior to the event which triggered the notification and some very initial reflection regarding practice and decision-making within that agency.

After consideration of the gathered data the nominated person or sub-group will then make a recommendation to the CPC on whether or not to proceed with a Learning Review. The recommendation will contain the following information (a link to a template is at Annex 1.3):

  • a brief outline of the case and the basis for referral
  • the current circumstances of the child and family and what actions have been taken
  • any other formal proceedings underway including criminal investigations or ongoing criminal proceedings

The subsequent decision on whether or not to proceed with a Learning Review will be accompanied by (a template for a Learning Review Decision is at Annex 1.4 and a Learning Review Notification Response is at Annex 1.5):

  • (if yes) proposed terms of reference of a Learning Review, as well as a Family Liaison Strategy for ensuring appropriate communication and support (see section 4 and Annex 4)
  • (if not) consideration of an alternative approach for learning (see the section on ‘If a situation does not meet the criteria for a Learning Review’ page 10)
  • an assessment of the likely communication and media issues, as known at the time

The Chief Officers Group should be informed of the recommendation and of the subsequent decision about whether to proceed with a Learning Review or the reasons for not doing so.[2] The Care Inspectorate will also be informed. This will be done via an electronic notification form.

If the decision is to go ahead with a Learning Review then a review team will be established, and a Chair and Reviewer(s) appointed.

Potential media interest

Consideration of potential media interest should be discussed by the CPC and Chief Officers Group (COG). When cases are likely to attract high public and media interest, a strategy should be prepared allowing for a range of scenarios. Media statements should make it clear that the purpose of the review is learning and not culpability.

When dealing with Learning Reviews which are likely to attract high levels of media attention CPCs and Chief Officers Groups should consider the impact on the staff and families involved in the review, advising and supporting them as much as possible. This includes those likely to be approached by the media for statements or who may be put forward as spokespersons. Whilst general media training or coaching is helpful it can be more effective to hold training sessions focused on the specifics of the Review in question.

It is advisable that key local and national partners, particularly the Scottish Government, are made aware that media enquiries are anticipated, including when the decision is not to proceed with a Learning Review. This may include sharing the strategy and any pre-prepared statements with them so that they can provide an informed and agreed response.

The email address for informing and liaising with the Scottish Government is:

Timeframe for the initial decision-making process

The timeframe for this initial decision-making stage will vary depending on the situation being considered. However, timeliness is important, so that any learning arising is relevant to the current practice context. Clear systems and mechanisms for arriving at a decision will facilitate and expedite the process. It is suggested that 28 to 42 days from the receipt of a referral would be an appropriate and realistic timeframe for the completion of this initial process.

More than one Child Protection Committee is involved

In the case of a potential cross-authority Learning Review within Scotland, the relevant CPC Chairs should meet and agree a mechanism for joint working, including which CPC should take the lead and if required, joint commissioning of the Reviewer and agreement on the composition of the Review Team. It will also be important that clear channels are identified for how information is shared across local authorities. Any disputes (between local authorities) should be escalated to the relevant Chief Officers Group for consideration.

In the case of a potential cross-border Learning Review, the CPC Chair should meet with the relevant Chair of the Safeguarding Children Partnership (in England) or with the Chair of the Regional Safeguarding Children Board in Wales or the Chair of the Safeguarding Board for Northern Ireland to agree a mechanism for joint working.

If the subject of a review is a young person over 18 who was looked after by or receiving continuing care from the local authority, then recognition should be given to their status as an adult. It may be appropriate, therefore, to work alongside the Adult Support and Protection Committee. The CPC Chair should meet with the ASPC Chair to agree how the review will be conducted and who will take the lead.

More than one child

There may be cases where more than one child has died or sustained significant harm as a result of abuse, harm, neglect or exploitation and each child is the subject of the same Review. The review process must consider each child’s perspective and experience individually but ensure that learning arising from the children’s circumstances is brought together in one Learning Review report at the conclusion of the Review.

The Learning Review and other formal staff processes

If any issues of staff malpractice or competency emerge during the course of a Review these should be referred to and managed by the relevant agency’s own staff procedures. Learning Reviews are about multi-agency learning in order to improve future practice. They are not investigations or a means of dealing with complaints.

If a situation does not meet the criteria for a Learning Review

There will be some situations where, after careful consideration, it is decided that the criteria for undertaking a Learning Review have not been met. However, the situation may contain some valuable reflective learning for practitioners and services and therefore it is important that CPCs give consideration to what might be learned and how that learning can be disseminated to the multi-agency workforce.

There are several ways in which this learning can be accessed such as facilitated multi-agency or single agency reflective sessions or other quality assurance or evaluation processes. Whatever the approach they are all part of a continuous programme of learning and development. As such they need to conclude with a short and succinct report identifying key learning and if appropriate, some multi-level strategies for changing, improving, or strengthening practice in the future and for sustaining effective practice. Learning points should be aligned to the quality indicators set out in the Care Inspectorate – A Quality Framework for Children and Young People in Need of Care and Protection (2019).



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