Serious Case Reviews

Working Together to Safeguard Children 2008 states that the safeguarding partners should agree how reviews are conducted, to ensure there is a way of looking at and analysing frontline practice as well as organisational learning.

Rooted in earlier statutory guidance is one of the fundamental principles of the SILP methodology i.e conducting reviews which engage professionals who were involved in the case at the time.  The guidance allows us the flexibility to continue using our approach across a wide range of reviews and its expectations about overview reports accord with our philosophies eg. sound analysis to explore ‘the why’, accessibility, plain english etc.

Our reviews embrace the ideal of proportionality, and we offer a wide range of approaches which have established SILP as an effective learning model, no matter what the scale of the review. 

We continue to work with boards to conduct reviews of cases which do not meet the criteria for an SCR, but which can provide valuable learning. 

Systems Methodology

We welcome the requirement in earlier statutory guidance that Serious Case Reviews and management reviews should be conducted using systems methodology. The SILP method is rooted in systems methodology, taking its influences from Eileen Munro in 2005, who urged we should try to understand ‘WHY the mistake was made, by studying interacting factors in the practitioners, the resources available, and the organisational context.’ 

Tried & Tested

The SILP model has been in use since 2009. Having now evolved and being registered as a trademark, it has been used in over 100 case reviews. SILP Acrredited Lead Reviewers are required to pass a 3 day University Accredited Training Course which involves participating in a Simulated Learning Event as well as preparing a written submission.

We now have more than 40 SILP Accredited Lead Reviewers, who benefit from mentoring, supervision and our online resource library.  Our reviewers are required to maintain annual refresher training.

SILP has been described by participants as action learning, who have commented on the problem solving approach and quality of outcomes :

‘The SILP process allows for more meaningful learning, its less threatening for practitioners, so they are willing to engage as all agencies work together to identify the learning outcomes with the help of the facilitator, rather than being told what they are by a panel. The SCR can lose sight of the learning in favour of producing a good enough report.’ Designated Lead Nurse for Safeguarding.

‘ I had lost sight of the child in my recording and focused on the adults needs. The SILP process, albeit a painful experience was extremely therapeutic. The multi-agency element has changed my recording practice to be more robust on the purpose of contact, detailed analysis and planned outcomes for the child’ 

Experienced Health Visitor

The Principles of SILP

The key principle of SILP is the engagement of frontline staff and first line managers in conjunction with members of LSCB Serious Case Review Panels or Subcommittees, Designated and Specialist Safeguarding staff, etc. The involvement of frontline staff and first line managers gives a much greater degree of ownership and therefore a much greater commitment to learning and dissemination. The SILP is a collaborative and analytical process. The main focus is to extract learning from the detailed study of a set of circumstances. From a worker’s point of view it takes account of:

  • your view of what was going on in and around this case

  • how you understood your role or the part you were playing

  • your thinking and your context at the time

  • your perspective on what aspects of the whole system influenced you as a worker • the tools you were using 

By taking account of these things, the process focuses on understanding why someone acted in a certain way. It highlights what factors in the system contributed to their actions making sense to them at the time. This process is NOT about blame or any potential disciplinary action, but about an open and transparent learning from practice, in order to improve inter-agency working.  Importantly, it also highlights what is working well and patterns of good practice.