A Guide to Case Management Reviews

What is a Case Management Review?

Throughout the UK, formal inquiries are carried out in order to understand and analyse cases where abuse or neglect is known or suspected and a child has died, or been seriously harmed. Each region has its own name for its local inquiries – Case Management Reviews are relevant to Northern Ireland. Please select another region to find out about its type of inquiry: England, Wales and Scotland.

Child abuse and neglect

Reviews are required when children come to serious harm following abuse and neglect. Lord Laming (2009) stated reviews are an important tool for learning lessons. Despite the recognition of the opportunities reviews which provide to improve child safeguarding practice, child abuse is still occurring. 

In recognition of shortcomings in child protection, highlighted by the tragic deaths of Baby P, Victoria Climbié, Daniel Pelka, Holly Wells and Jessica Chapman, the government has developed new review protocols and guidance to provide an increasingly robust framework to reduce the risk of child abuse. This is set out in ‘Working Together to Safeguard Children’ (2018).

Here we intend to help you to understand the foundations of current policy, whilst highlighting where child protection has failed, to enable you to support your professional curiosity and efficacy as a frontline practitioner.

Local Safeguarding Panels (replacing Health and Social Care Trust Protection Panels)

Safeguarding panels are independently chaired committees of the Safeguarding Board for Northern Ireland (SBNI). Each Panel is responsible for overseeing child protection practice at a local level.

When a child experiences neglect and abuse, irrespective of the outcome, the panel is responsible for reporting to the SBNI to enable them to decide if a Case Management Review (CMR) is required.

Local Safeguarding Panels are located in six of the Health and Social Care Trust areas:

• Belfast Health and Social Care Trust
• Northern Health and Social Care Trust
• Northern Ireland Ambulance Service Health and Social Care Trust
• Southern Eastern Health and Social Care Trust
• Western Health and Social Care Trust

Safeguarding Board for Northern Ireland (SBNI)

The SBNI was established by the Department of Health, Social Services and Public Safety (DHSSPS) in 2012. It recognises that child protection and safeguarding practices are more effective when there is good multi-agency working in place. The board must follow any guidance provided by the DHSSPS.

The board includes representatives from health, social care, the police, the probation board, youth justice, education, district councils and the NSPCC.

The main role of the SBNI is to:

• Ensure agencies, individuals and organisations understand why child protection is important.
• Monitor the effectiveness of work carried out by agencies who are part of the Board.
• Report to the Northern Ireland Government (Department of Health) about the work they have engaged in and what they have found.
• Monitor child mortality rates
• Provide advice and guidance to agencies that are part of the Board
• Hold discussions with children, young people and families to gather their views on child protection and safeguarding practice.

Case Management Reviews (CMRs)

Section 3(4) of the Safeguarding Board (NI) Act 2011 requires the SBNI to undertake reviews when there are concerns about the effectiveness of safeguarding and promoting the welfare of the child. The purpose of a CMR is to:

• Strengthen the child protection system
• Examine organisational systems and processes to assess their effectiveness
• Establish the facts of the case
• Identify what worked well
• Support continuous development and learning
• Decide if there are lessons to be learned from a case, particularly looking at the ways in which professionals work together to safeguard children and young people
• Establish what the lessons are, what action will be taken and what is expected to change.

When is a CMR conducted?

The SBNI is required to hold a Case Management Review when a child has died or been significant harmed and any of the following apply:

• Abuse or neglect of the child is known or suspected.
• The child or a sibling of the child has been placed on the child protection register.
• The child or a sibling of the child has been looked after by an authority.
• The Safeguarding Board has concerns about the effectiveness in safeguarding and promoting the welfare of children.
• The Safeguarding Board determines there is significant learning to be gained from the case management review which could lead substantial improvements to safeguarding practice.

View an example of a CMR by the SBNI.

Questions assisting effective CMRs

What happened? Overview of the case to establish the facts.

What could have been done to prevent the abuse and/or neglect? What actions could have been taken to stop the abuse from happening?

Is there typicality in the contextual factors and the responses of agencies? Are there similar challenges or difficulties within agencies that could have contributed to the abuse and/or neglect?

What changes to the way in which agencies operate could help to prevent abuse/neglect? Identifying actions that could improve child safeguarding procedures to reduce the risk of harm to children and young people.

Have agencies changed their practice as a result of this learning? What changes in organisations have been made to support improvement in child safeguarding practice?

Public Inquiries and Serious Case Reviews: Foundations for Change

There have been many public inquiries and serious case reviews in England highlighting areas for improvement and development in child safeguarding policies and practice.  

Some high-profile child protection cases have been significant in driving change and improvement. Select each one for more information.

Public Inquiry:  Holly Wells and Jessica Chapman (Sir Michael Bichard, 2004)

Public Inquiry: Victoria Climbié (Lord Laming, 2003)

Serious Case Review: Baby P (2009)

Serious Case Review: Daniel Pelka (2013)

The NSPCC have put together a National Case review repository detailing cases from across the UK, you can access the repository here.