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.

4. Undertaking the Learning Review

A systemic approach

This guidance is not prescribing a model for undertaking a Learning Review as it is recognised that CPCs have a variety of review models that work well for them. However, it is important to emphasise that a Learning Review is a collective endeavour and that, whilst the detail of how a review is undertaken may vary, all reviews must adopt a systemic approach. Such an approach goes beyond individual or professional practice to explore underlying systemic factors, the links with organisational factors and the wider contexts. The central idea is that any professional’s performance is a result both of their own skills and knowledge, and of the organisational setting in which they are working. A Learning Review, therefore, must focus on understanding how people saw things at the time, why things happened as they did, what belief systems were operating and how capabilities and capacity were affected by the roles and positions adopted by family members and other professionals, together with the emotional impact of the work and the resources available.

An effective systemic model has the following components:

  • it is truly participatory and collective, involving all relevant professionals, managers, agencies, and families
  • all participants in the Review contribute to the critical reflection and analysis of the situation under review and the development of strategies to support practice and improve processes and systems across agencies
  • it adopts an analytical and evidence-based approach
  • there is an appreciation that learning is not something ‘done’ to people but rather something that people themselves do and own
  • it takes learning to a deeper level by examining systems, structures, and cultural and contextual factors
  • it explores the interrelated and interdependent parts of different services and agencies and the impact this has had on the lived experience of the child who is the subject of the review
  • it explores how user/human friendly systems are for children and families, as well as professionals
  • it does not focus solely on what went wrong but also includes an examination and analysis of effective practice
  • learning does not just come at the end of the Review once the report is published, there is a ‘thread of learning’ throughout the review process. The learning develops with each Review Team meeting and professionals’ event, as hypotheses are formulated and tested, and issues identified and explored
  • the learning from a Review is disseminated and implemented in practice and in systems at both a local and a national level

The Review Team

When a decision has been made to proceed to a Learning Review the first step is to set up a Review Team. The Review Team manages the whole process of the Review and is a multi-agency group whose members should have a working knowledge of the relevant services involved in supporting children and families (including child protection and adult services), but, as far as possible, does not have direct involvement in the situation under review. Consideration must be given to ensuring a group size that is conducive to learning and joint working. The number and composition of the Review Team will be specific to each case and there may be situations where the initial membership will need to be adjusted after the first meeting of the Review Team, based on a better understanding of the situation under review. Nevertheless, efforts should be made to ensure consistent participation of all members throughout the Review and to keep membership changes to a minimum.

It is the Review Team’s responsibility to ensure the Learning Review remains proportionate and focused and is conducted in accordance with the underlying principles and values set out in Section 2 of this Guidance.

The Review Team works together within a culture of collaborative problem solving to review and assess all information available; clarify issues for further exploration and to identify any gaps or deficiencies in the information available to the Review. The Review Team brings to the task the ability to reflect; to analyse and to look at the wider impact for practice and service delivery.

The Review Team consists of the separate roles of:

  • the Chair
  • team members
  • the Reviewer(s)
  • the Administrator

The role of the Chair of the Review Team

The key components of the role of the Review Team Chair are to:

  • consider whether there are parallel processes ongoing i.e. criminal proceedings/FAI. This will involve making enquiries to establish whether there is an ongoing criminal investigation or ongoing criminal proceedings (see Annex 2)
  • coordinate the identification and engagement of the relevant partners and suitable contributors to the Learning Review
  • coordinate the work of the Review Team
  • ensure that a clear and realistic timetable for the review process is set out and is adjusted where and when needed
  • ensure timely requests are made for key documentation relevant to the Review from organisations involved in the situation under review and to follow up instances when that information is not provided in a timely manner
  • chair and facilitate meetings of the Review Team
  • contribute to the development of the learning emerging through the review process
  • ensure the review process has a consistent child-centred perspective throughout
  • meet with family members alongside the Reviewer as appropriate
  • attend practitioner and manager events alongside the Reviewer

The role of the Review Team members

Members of the Review Team have an important role to play in the process and outcome of the Learning Review and therefore, it is important that they manage and prioritise different work demands so that sufficient time is allocated to the Review.

The main aspects of the role of Review Team members are to:

  • attend the meetings of the Review team
  • contribute to the collection and collation of information throughout the Review
  • identify any gaps or deficiencies in the information available to the Learning Review and seek to remedy this
  • act as an interface between their service or organisation and the Learning Review Team, contributing to all practical aspects of the Review that are required from their service or organisation
  • identify those professionals within their service or organisation who will be part of the Review
  • help participants to feel informed and supported when they enter the Review, as well as throughout and at the end of the review process
  • contribute to the identification of emerging themes and issues
  • participate in the verification, interpretation, and analysis of the information
  • assist in the drafting of the Review report by critical and constructive appraisal

The role of the Reviewer

The overarching role of the Reviewer is to facilitate and manage the learning emerging throughout the review process and to take responsibility for the production of the report at the end of this process which brings together all of the learning into a coherent whole.

The essential elements of the Reviewer’s role are therefore to:

  • work collaboratively and transparently with the Review Team Chair and members
  • attend the meetings of the Review Team
  • review and assess all information available to develop a full and multi-faceted understanding of the case
  • interpret and analyse the workings and shortcomings of complex, multi-agency systems
  • establish effective relationships with contributors to the Review
  • effectively facilitate group work and manage complex group dynamics
  • facilitate practitioner and manager events so that:
    • participants understand the purpose of the Review as well as the underpinning principles and values of Learning Reviews
    • trust is established between participants
    • all participants can voice their views in a safe manner
    • discussion, debate, probing, and constructive challenge are encouraged
  • use a range of participatory and creative approaches to obtain the views and experiences of children, young people, and their families
  • pull together the learning and write the report, with the assistance of the rest of the Review Team

In some circumstances it may be appropriate to have two Reviewers. For instance, if a case is particularly complex or there is more than one child who is the subject of the Review, or sometimes as a means of increasing the competence and confidence of someone new to the role of a Reviewer. When there is more than one Reviewer it will be important that they work closely together and agree how tasks will be allocated.

The role of the Administrator

To support and coordinate the Learning Review process it is essential that high quality administrative support is in place. The Administrator is an important member of the Review Team and the key aspects of this support role are to:

  • administer meetings and events that are part of the Review, including scheduling Review Team meetings, booking venues, managing some financial arrangements, and supporting with other associated practicalities
  • take minutes and notes of Review Team meetings and practitioner and manager events
  • support the communications of the Review Team, including collating, distributing and storing documents and information as required

Skills, attributes, experience, and knowledge

The skills, attributes, experience, and knowledge associated with the various roles within a Review Team are outlined in Annex 5, which is intended to support the local process of appointment and, where suitable, the specific training and coaching arrangements. These will be dependent on the nature of the Review and the requirement of the Child Protection Committee and Chief Officers Group.

Enabling factors within the wider context

A supportive Chief Officers Group is an essential enabling factor in ensuring that Learning Reviews are effective and fulfil their purpose. This means the Chief Officers Group taking ownership of and a constructive interest in the review process, findings and learning, with strategic level commitment to implement the actions and learning stemming from the Review.

There needs to be sufficient budget in place to resource Learning Reviews, for example if an Independent Reviewer is needed or for coaching and training staff in Learning Review methodology, as well as to support wider learning opportunities across areas. Staff time must be made available to the Learning Review process and recognition that Review Team members may need to devote multiple days to the Review over and above their day-to-day work responsibilities.

Terms of reference

Terms of reference are a guiding statement which define the scope of the Learning Review. Terms of reference should reflect the rationale for undertaking a Review and be relevant and specific to the situation under review. Based on the information known at the time, proposed terms of reference will have been drawn up at the point a recommendation is made to the Chair of the CPC to proceed with a Learning Review. It should be noted that terms of reference are a living document and, once the Review is underway, may need to be amended as further information is collated by the Review Team. The CPC should be informed of and in agreement with any changes to the terms of reference.

The final terms of reference will be included in the Learning Review report at the completion of the Review.

Collecting and collating further information

The preparation of single agency chronologies is an important first step in the collection and collation of further information. The decision about how far back to go in terms of the timeframe preceding the incident will, to a certain extent, be dependent on the situation under review. However, in the interests of proportionality, timing, and timeliness the guiding principle must be that chronologies cover as short a timeline as possible. In most instances two to three years preceding the incident should be sufficient. If agencies and services have been involved with a child and their family for many years, then a brief summary of that earlier involvement should be prepared.

Chronologies might not necessarily conclude at the point of the precipitating incident. Sometimes the responses of agencies in the immediate aftermath will provide useful learning and should be part of the Learning Review.

Once single agency chronologies have been compiled, they will be merged, thus providing the Review Team with an overview of the situation from which issues can be identified and questions developed in order to begin to explore what happened in the situation under review. Information on systems, structures, and cultural and contextual factors will also be explored in order to enhance the overview of the situation.

As the Review progresses gaps in information will emerge and it is the responsibility of Review Team members to facilitate the gathering of any additional information or access to other pertinent documents. This will ensure that the Reviewer and the Review Team have sufficient information to conduct the Review.

Managing emerging issues and challenges during the Review

There may be instances, when, during the course of a Learning Review, an issue arises that may challenge or confuse or add further complexity to the review. If this should happen it is important that the Terms of Reference are revisited, potentially leading to pausing the review process in order that the Review Team consider sources of advice and an appropriate strategy for moving forward. If it is likely that an issue or challenge will delay the review reaching its conclusion then the CPC and the COG must be informed.

Engaging the family in the Review process

A Learning Review is a collective endeavour to bring together agencies, individuals, and families to learn from what has happened in order to better protect children and young people in the future. As the family are, therefore, integral to Learning Reviews, the Review Team must consider how to involve them in the process in a meaningful and sensitive way by developing a Family Liaison Strategy as per Annex 4.

The purpose of engaging with the family is to explore their perspective and to elicit their opinions about the practitioners and services who were involved in their lives. This will include what they found helpful or unhelpful and their suggestions for how services to children and families could be improved. Their thoughts, opinions and feelings contribute to the overall learning of the Review.

Careful consideration should be given as to who constitutes the family group. This will differ from Review to Review but may include:

  • parents
  • step parents
  • carers
  • siblings
  • grandparents
  • aunts and uncles
  • the child/young person
  • other significant family members, including partners or spouses
  • close family friends

The family should be informed as soon as possible that a Learning Review is being undertaken and the purpose of that Review should be clearly stated. Inviting them to take part in the Review must be done sensitively. If there are professionals still involved with the family then they may be involved as appropriate in explaining to families the purpose of the Review and ascertaining their wishes as to if, how and when they want to be involved.

If family members wish to participate in the Learning Review, then a decision will be made as to who, from the Review Team, should meet with them and where. Usually this would be the Reviewer accompanied by either the Review Team Chair or a Review Team member. Where and how to meet will be dependent on the wishes of the family; it may be at the family home or at a neutral venue or online. It is also important to note that it may not be appropriate to meet all family members at the same time. There may have to be more than one meeting.

It is helpful if meetings with the family can be arranged before any practitioner events or managers’ events. This means that the family views can be taken into those forums for reflection and discussion.

At the end of the review process arrangements should be made to feedback to the family the conclusion of the Review, the learning contained within the report and any strategies to improve practice and systems in the future. Again, this must be approached in a sensitive manner as the family may not agree with the findings of the Review. The family should also be asked how they found the process of the Review itself and their feedback should inform the conduct of future Learning Reviews.

The feedback may have a number of functions for the family. It may provide validation or reassurance, but it may also cause distress or revive painful memories. In some circumstances support from professionals may need to be available to family members.

Families and others involved in Learning Reviews may well be suffering from trauma. There is a commitment to ensuring that Scotland has a workforce that is fully aware of the impact of trauma, and is equipped to respond appropriately to people who have experienced trauma at any age. Information on this can be found at Scottish Government: Adverse Childhood Experiences – Trauma Informed Workforce.

Scotland was one of the first countries in the world to develop a robust Knowledge and Skills Framework for Psychological Trauma. This framework lays out the essential core knowledge and skills needed by all tiers of the Scottish workforce to ensure that the needs of children and adults who are affected by trauma are recognised, understood and responded to in a way which recognises individual strengths, acknowledges rights and ensures timely access to effective care, support and interventions for those who need it.

A National Trauma Training Programme has been established to implement this knowledge and skills framework and to support all sectors of the workforce to upskill staff in trauma-informed practice, as well as to embed and sustain this model of working. The programme of work is being led by NHS Education for Scotland (NES) and informed by people with lived experience, to create and deliver quality training resources.

Involving practitioners, first line managers and strategic managers

Whilst this Guidance does not prescribe a particular model for undertaking a Learning Review, all Reviews must adopt a systemic and proportionate approach. Such an approach should be participatory and collective and, as well as engaging with families, should involve all relevant staff. This will include those practitioners and first-line managers who were involved in the situation under review as well as strategic managers, who, though not directly involved in a review situation, are responsible for the development of processes and structures to facilitate the delivery of services to children and their families.

Bringing together practitioners and first line managers in a group ensures that their voice directly contributes to the Review and has two distinct purposes:

  • firstly, it enables them to describe what they did and why; to reflect on and analyse assessments and decision-making at the time and to identify what could have been done differently but also what prevented them from doing this. It also enables the group to recognise effective practice and what worked well and why
  • secondly, it generates immediate learning, at both an individual and at a group level, that can be taken back into practice

For strategic managers, meeting as a group is an opportunity to understand the learning from a particular situation in order to consider the implications from both a single agency and a multi-agency perspective.

Annex 6 looks at how to facilitate and shape events for practitioners, first line managers and strategic managers.

Review Team meetings

Regular meetings of the Review Team should be scheduled throughout the course of the Learning Review. The overall purpose of these meetings is to review the progress of the Review, identify the emerging learning, highlight issues and questions for further exploration, set out the next steps and allocate tasks.

The focus of each Review Team meeting will differ depending on the stage in the review process. For instance, in the early stages collating information, identifying any significant gaps in that information, and clarifying which practitioners and managers should be involved in the Review and how they will be supported to participate effectively will be on the agenda. As the Review progresses the Review Team meetings will consider the learning emerging from contact with family members and from the practitioner and manager events. In the latter stages of the Learning Review the focus will be on the construction of the report.

All information processed by the Review Team must be kept secure, particularly given its sensitivity, and should be relevant to and necessary for the Review, rather than excessive. This information will be retained in perpetuity.

The Report

The purpose of a Learning Review report is to identify key learning points and how and why that learning has emerged throughout the review process. Reports should be clear, succinct, and as anonymous as possible. This will simplify any process of redaction of Personal Data prior to circulation for learning purposes or wider publication and ensure that the redacted report is still meaningful. When this is not possible, detailing Personal Data in particular sections of the report, rather than including with more general content, is recommended.

Where a living individual can be identified from the report or even from the report and other information held, this will be Personal Data and so data protection principles, including a data subject’s right of access, will apply. Personal Data includes opinions and indications of intentions. A Learning Review, by its very nature, will contain professional opinions, but it is important that these are recorded as such and distinguished from fact.

Whilst it is the responsibility of the Reviewer to pull together the learning and draft the report, this should be done alongside the Review Team whose role is to scrutinise, challenge appropriately and ensure that the report represents all the learning that has been generated by the Review process.

The report content should cover (a link to a report template is at Annex 1.6):

  • a brief description of how the Review was conducted
  • a brief outline of the circumstances that led to the Learning Review
  • the practice and organisational learning that has been identified and the evidence substantiating this learning
  • examples of effective practice in the situation under review and the reason why it was effective
  • suggested strategies for improving practice and systems. It must be noted that in some situations the Review Team may conclude that practice and processes have not failed or been inappropriate and, therefore, at this point no changes are required

It is recommended that suggested strategies for improving practice and systems should be CLEAR.[3] This means that:

  • Case for change: the Review Team should clearly identify the issues that give rise to the need for change, outlining the likely consequences should no change occur. Any proposed change should be set within the context of current policy or that which is known to be in preparation.
  • Learning orientated: any suggested strategies should highlight key lessons for practice identified by the review process and should promote the transfer of learning.
  • Evidence based: proposed strategies for improving systems and practice should draw on evidence of any shortcomings in policy or practice revealed by the Review and only be made if evidence exists that their implementation will effectively address the shortcomings identified in the Review report.
  • Assign responsibility: each strategy should identify the discipline or organisation with responsibility for implementation, recognising that some will require a collaborative response.
  • Review: any strategies recommended by the Review report should be amenable to review. This can be done by specifying desired outcomes and timelines and any additional resources required to achieve them.

The Learning Review report will be presented to the CPC and the COG for consideration and sign off. It is recommended that the Reviewer and the Chair of the Review Team take responsibility for presenting the report.

Publishing the Report

The COG, informed by a recommendation in this regard from the Child Protection Committee, will decide if and when to publish the report. In making this decision issues of confidentiality and data protection principles must be considered. The family should also be consulted, and their views taken into account and given due weight in arriving at a decision. Any publication must be suitably anonymised but also clearly reflect the learning emerging from the Review and the evidence for any proposed changes. Where a decision not to publish the report is reached, the exceptional circumstances underpinning that decision will be noted in the minutes of the COG meeting. If a report is not published, then the learning should be extracted from the report and be published separately.

Even if a decision is reached not to pro-actively publish the report, there is always a possibility, particularly in high profile cases, that a Freedom of Information (FOI) request may be received. In such cases the relevant public authority will be obliged to disclose information on request, unless one of the fairly narrow exemptions apply, particularly where there is a public interest in doing so. Although there is an exemption for Personal Data when disclosure of which would breach the data protection principles, it may be difficult to justify withholding the report in its entirety and it may need to be issued under redaction of Personal Data.

It is important to note that publication of the report may need to be delayed until the conclusion of criminal or FAI proceedings. Where criminal, FAI or children’s hearings proceedings are ongoing the publication of any report must be discussed with COPFS and/or SCRA. See Annex 2 for further information.

Timescale for the Learning Review

If the learning identified throughout the review process is to be relevant and helpful to the development and improvement of child protection practice and processes it is important that the Review is completed as soon as possible. Once a decision has been made to undertake a Learning Review, the process should be completed within a timeframe of six to nine months, thus avoiding drift.

However, in some situations there may be some unavoidable delay at any stage, for instance because of parallel processes. The Chair of the Review Team should communicate the reasons for any delay back to the CPC, with a revised timescale. Lengthy delays should be avoided because of the impact on both staff and families involved.

Learning Review Process Map

1. Notification form

To be reviewed by the nominated person or sub-group within CPC

2. Request for and collection of further information:

  • ‘Request for Information’ form
  • Relevant agencies provide brief account of involvement and some very initial reflection

3. Consideration of information gathered, by the nominated person or sub-group within CPC

A) Recommendation not to proceed with consideration of Learning Review:

  • Recommendation template
  • Suggested alternative approach for learning

B) Recommendation to proceed with consideration of Learning Review:

  • Recommendation template
  • Proposed terms of reference

4. CPC meet to consider the recommendation

A) Decision not to proceed with learning review

B) Decision to proceed with learning review

5. Recording and communicating the decision:

  • ‘Learning Review Decision’ form
  • Informing the Chief Officers Group
  • ‘Notification Response’ form
  • Notifying the Care Inspectorate
  • Communication and media approach (where relevant).

A) Consider alternative approach for learning (if the decision is not to undertake a Learning Review)

B) Proceed with Learning Review:

  • Learning Review arrangements:
    • Learning Review Team set up
    • Family Liaison Strategy
    • COPFS /MA meeting re. parallel reviews (where relevant)
  • Learning Review process
    • Collecting and collating further information (including chronologies)
    • Review Team meetings
    • Liaising with family (as per strategy)
    • Involving practitioners and managers
    • Considering emerging learning
    • Completing the National Child Death Review Dataset (where relevant)
  • Learning Review Report for CPC and COG; (also sent to CI) + Action Plan for Dissemination of Learning



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