Learning Reviews and Processes linked to incidents of serious harm or death

Effective liaison is required between the relevant multi-agency strategic partnerships or lead agencies to determine the most appropriate review process that maximises learning, minimises duplication of effort and reduces anxiety for families involved.

Child Death Review

Lead: Local Authorities and Integrated Care Boards (ICBs)

Purpose: A Child Death Review must be carried out for all children regardless of the cause of death. The purpose of a Child Death Review is to identify any matters relating to the death, or deaths that are relevant to the welfare of children in the area or to public health and safety.

Child Safeguarding Practice Review (CSPR)

Lead: Safeguarding Children Partnership.

Purpose: Statutory, multi-agency reviews where abuse of a child is known or suspected and the child has died or been seriously harmed (referred to as a serious child safeguarding case). A multi-agency rapid review will be undertaken initially to determine whether a Child Safeguarding Practice Review is required.

Coroner’s Inquest / Prevention of Future Deaths

Lead: HM Coroner

Purpose: A Coroner must hold an inquest if there is reasonable cause to suspect that the death was due to anything other than natural causes. An inquest must also be held when a person has died whilst in state detention (e.g. prison/police custody).

An inquest into a death which appears to be due to unknown, violent or unnatural causes, designed to find out who the deceased was, and where, when and how (meaning by what means the person died). At the end of the inquest, the Coroner will give his/her conclusion about the cause of death. The Coroner can write a report in cases where the evidence suggests that further avoidable deaths could occur and that, in the Coroner’s opinion, preventative action should be taken. The report will be sent to the person or authority which may have the power to make appropriate steps to reduce the risk and they have a mandatory duty to reply within 56 days.

Criminal Enquiry

Lead: Police

Purpose:  To undertake an impartial, thorough and effective investigation into alleged offending, criminal or otherwise.  Police should gather available relevant material/evidence in a manner that is proportionate to the alleged criminality.  On completion of their investigation,  Police should assess the material/evidence and decide to either:

  • Finalise the enquiry without sanction (where there is insufficient evidence and other criteria or circumatnces).
  • Progress an Out of Court disposal (e.g. a caution or diversionary measure subject to set criteria and offence types).
  • Authorise prosecution and either formally charge or summons the suspect to appear at court (subject to set criteria).
  • Consult with the Crown Prosecution Service (CPS) for formal advice and authority to charge (subject to set criteria).

Domestic Abuse Related Death Review

Lead: Commissioned and coordinated by Community Safety Partnerships and overseen by the Home Office.

Purpose: Statutory, multi-agency review of the circumstances in which the death (including suicide) of a person aged 16 or over has, or appears to have resulted from violence, controlling or coercive behaviour, abuse or neglect by a person whom they were related or with whom they were, or had been in an intimate personal relationship, or a member of the same household as themselves.

Drug and Alcohol Related Death Review (DARD)

Lead: Public Health

Purpose: Non-statutory, multi-agency review to learn from deaths that are/suspected to be drug or alcohol related to help prevent future deaths and raise awareness of issues linked to substance misuse.

Fire Fatality Review

Lead: Fire Brigade

Purpose: Non-statutory Fire Fatality Reviews are completed after each accidental dwelling fire where an individual loses their life. The reviews are completed to assess the interaction between the organisation and individual members of the community to ensure that interventions reduce dwelling fire risk and people remain safe in their own homes. All historical contact, advice and interventions are assessed to determine whether as mush as possible had been done to prevent an accidental dwelling fire and the subsequent fatal outcome. The Fire Fatality Review draws in information from the initial crews responding to the incident, contact with partner organisations, comprehensive reports from the joint fire investigation completed with Police and the Brigade’s targeting methodology to determine the level of dwelling fire risk and whether the corresponding interventions were appropriate.

Fire Fatality Learning Reviews are generally completed internally within 28 days but may also include the attendance of specific partners depending on the circumstances of the incident. All learning elicited from each Fire Fatality Review is used to strengthen the systems and processes within the Brigade to achieve Safer Homes and the goal of Safer, Stronger Communities.

Learning from Lives and Deaths (LeDeR)

Lead: Integrated Care Boards (ICBs)

Purpose: LeDeR is a service improvement programme which aims to improve care, reduce health inequalities and prevent premature mortality of people with a Learning Disability and Autistic people by reviewing information about the health and social care support people received. Everyone with a Learning Disability aged four and above who dies and every adult (aged 18 and over) with a diagnosis of Autism is eligible for a LeDeR review, however the primary review process for children is the Child Death Review process.

Multi-Agency Public Protection Arrangements (MAPPA)

Lead: Probation, Police, Prison Service

Purpose: MAPPA are a set of national arrangements to manage risk posed by the most serious sexual and violent offenders under the provisions of the Criminal Justice Act 2003. A number of agencies are under a duty to co-operate (DTC) with the responsible authority including Social Services and Health Trusts.

A MAPPA Serious Case Review is coordinated by the MAPPA Strategic Management Board when an offender subject to MAPPA commits a Serious Further Offence (SFO). The purpose is to examine whether the MAPP arrangements were effectively applied and whether agencies worked together to do all they reasonably could to manage the risk of further offending in the community.

Multi-Agency Risk Assessment Conference (MARAC)

Lead: Police

Purpose: To provide a consistent (national) approach to the risk assessment of those individuals that have been identified at the highest risk of serious harm from domestic abuse (including coercive and controlling behaviour) in order to safeguard them and to enable appropriate actions to be taken to increase public safety.

The MARAC facilitates, monitors and evaluates effective information sharing between representatives of
the local police, probation, health, child protection, housing practitioners, Independent Domestic Violence
Advisors (IDVAs) and other specialists from the statutory and voluntary sectors and works on the
assumption that no single agency or individual is able to see the complete picture of the life of a potential
victim, but all may have insights that are crucial to their safety.

Domestic Abuse can be between intimate partners, former partners who still live together, or family members.

Multi-Agency Tasking and Coordination (MATAC)

Lead: Police

Purpose: A multi-agency process and response that will potentially reduce the risk of harm and/or recidivism to ensure the safety of those who are at risk or suffer domestic abuse. The protocol ensures a response to the most serial and prolific perpetrators in a way that minimises risks while ensuring choice, dignity and the rights of all are preserved.

MATAC is attended and supported by representatives from a range of partner agencies including police,
health, adult and children’s safeguarding, housing, probation services, mental health and substance
misuse as well as other specialists from the statutory and voluntary sectors.

Offensive Weapon Homicide Review

Lead: Police, Local Authorities, Integrated Care Boards (Partnership TBC, likely to be Community Safety Partnerships)

Purpose: Reviews into homicides where the victim is aged 18 or over, and the events surrounding their death involved, or were likely to have involved the use of an offensive weapon. The purpose of the review is to identify the lessons to be learnt from the death, to consider whether any action should be taken as a result, and to share the outcome. Local and national implementation of these lessons and any such actions are intended to help tackle homicide and serious violence.

Safeguarding Adults Review (SAR)

Lead: Commissioned and coordinated by the Safeguarding Adults Board.

Purpose: Statutory, multi-agency review where an adult (aged over 18) with care and support needs has died or experienced serious harm due to abuse/neglect and there is reasonable cause for concern about how agencies worked together to safeguard the adult.

Serious Incident (SI)

(Soon to be replaced with Patient Safety Incident Response Framework)

Lead: NHS England – Coordinated locally by Health Trusts and reported to the Integrated Care Board and shared with the Care Quality Commission.

Purpose: To review a serious incident(s) which has occurred within a health organisation, where a person has come to moderate/serious harm. This is to support learning and prevent recurrence. Each Health Trust will have their own internal process to determine if the criteria for an SI is met.

Single Agency / Management Reviews / Complaints

Every organisation will have their own single agency review or complaints process.