Serious incident review guidance

1.3 1.4 2. 2.1 Overview of serious incident reviews  Reviewing serious incidents is the responsibility of the local authorities1, often in consultation with partner agencies. This ensures relevant learning is identified in situations where someone subject to a statutory order or licence supervised by justice social work services has caused or been subject to serious harm.  Serious incident reviews (SIRs) provide a consistent framework to enable local authorities to examine the quality of practice and adherence to legislation and guidance. The reviews should focus on learning and reflection around day-to-day practices and processes, and the systems within which they operate. They should identify strengths as well as areas for improvement and are intended to contribute to a culture of continuous learning to strengthen future practice.  This guidance applies to the reporting of serious incidents involving people who are subject to a statutory social work order or throughcare licence following a final disposal by a court, namely:  • people subject to all and any requirements of a community payback order (including a stand-alone unpaid work requirement) • people subject to a drug treatment and testing order • people released from custody who are subject to the conditions of a throughcare licence (including a supervised release order and an order for lifelong restriction).  The Care Inspectorate collates all submitted serious incident reviews on behalf of the Scottish Government. This function is underpinned by the Care Inspectorate’s statutory duty to further improvement in the quality of social services, under section 44(1)(a) of the Public Service Reform (Scotland) Act 2010. To support effective practice, the Care Inspectorate reviews the effectiveness of the processes by which the serious incident review was conducted and provides feedback to local authorities.  To support continuous learning at a national level, the Care Inspectorate produces regular reports and a biennial report identifying strengths in practice and areas for improvement identified within the submitted reviews.   Criteria for identifying whether an incident is serious A serious incident is defined as an incident involving:  ‘…harmful behaviour, of a violent or sexual nature, which is life threatening and/or traumatic and from which recovery, whether physical or psychological, may reasonably be expected to be difficult or impossible.’  (Framework for Risk Assessment Management and Evaluation, RMA (2011) 1In most areas, justice social work services are delivered and overseen by the local authority, however in some areas, justice services are integrated within the health and social care partnership, overseen by the integration joint board. For the purposes of this guidance, when we use the term ‘local authority’, this also covers justice services, which are delivered as part of an integrated service.    2 2.2 A serious incident review (SIR) should always be carried out when: • a person on a statutory order (see 1.2) or licence is charged with and/or recalled to custody on suspicion of a further offence that has resulted in the death or serious harm of another person  • the incident, or accumulation of incidents, gives rise to significant concerns about service involvement or lack of involvement • a person on a statutory order or licence (see 1.2) has died or been seriously injured in circumstances which indicate the need for public assurance.  2.3 2.4 2.5 2.6 2.7 Appendix 1 lists examples of the kind of offences that may contribute to a seriously harmful incident.  These are examples only. Some offences noted may not result in serious harm and other offences not listed should not be excluded if they meet the criteria for risk of serious harm.  Appendix 2 offers illustrations of the kind of circumstances when a serious incident review should be considered.   When a person on a statutory order or licence dies or is seriously injured, the circumstances of the person’s death or injury may result in a need for services to provide assurance. This may be in relation to public safety and/or the effective provision of public services. Local authorities use several processes to record and report when a person receiving a justice social work service has died. A serious incident review submission to the Care Inspectorate is required when circumstances indicate there is a need to capture relevant learning to improve practice and/or provide assurance regarding public safety. Responsibility for completing a serious incident review sits with local authority justice social work services.  It differs in focus from a significant case review (SCR) relating to incidents involving people managed under MAPPA (Multi-Agency Public Protection Arrangements).  The purpose of the latter is to examine whether agencies effectively applied MAPPA arrangements and whether the agencies worked together effectively. In these circumstances, the chair of the MAPPA strategic oversight group (SOG) is responsible for commissioning the significant case review. The process map in section 3 provides detail on what action is required when the SOG decides there will be no significant case review. This guidance does not affect the existing arrangements for notifying the community licence team within the Scottish Government of incidents involving persons subject to statutory supervision following release from custody.   Where the nature or seriousness of an incident is likely to generate high levels of public, media, or parliamentary attention, the local authority should consider developing a communications strategy. In exceptional cases, particularly where interest is anticipated at a national level, it may be advisable to notify the Scottish Government’s community justice division and other key local and national partners as appropriate. This may include sharing the communications strategy and any prepared statements with the Scottish Government to enable it to provide an informed response if necessary. It may also be appropriate to share an anonymised version of the serious incident review, though this should be discussed with the Scottish Government on a case-by-case basis. Consideration should also be given to the impact on staff and people involved in the case to ensure they are offered appropriate advice and support to deal with any resulting enquiries.