Initial Case & Serious incident review guidance
1. Overview of serious incident reviews
1.1 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.
1.2 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).
1.3 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.
1.4 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.
2. Criteria for identifying whether an incident is serious
2.1 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)
1
In 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.
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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 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.
2.4 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.
2.5 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.
2.6 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.
2.7 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.
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3. Serious incident review process and guidance
The flowchart shows the proce