Serious Case Management Reviews

The Isle of Man Safeguarding Board has a legal responsibility to undertake Serious Case Management Reviews (SCMRs). This is when serious harm has occurred to a child, young person or vulnerable adult and there may be concerns about the way the different agencies have worked together to safeguard the person(s) in question. 

The purpose of an SCMR is to review cases and identify whether there are lessons to be learned from the way agencies worked together on the case, identify what those lessons are and how they will be acted upon and improve inter-agency working as a result. 

Reviews must focus on learning not blaming and engage practitioners and managers in recommending ways the safeguarding system and practice can be improved or strengthened. It is critical that reviews also focus on what worked well, to allow front line staff and managers to build on identified good practice.

The Serious Case Management Review (SCMR) Panel is responsible for: 

  • Considering referrals for SCMRs;  
  • Commissioning SCMRs  and other case reviews; 
  • Monitoring the action plans arising from reviews;
  • Ensuring the dissemination of the learning from reviews. 

As stated, reviews are not about apportioning blame and are not part of investigations by the Isle of Man Constabulary, the Director of Prosecutions, the Coroner of Inquests or of disciplinary or other process. 

The Isle of Man Safeguarding Board has published the following reviews:

In 2019 Family G was published. The review was commissioned to review the practice in relation to the care and support of several children between 2002 and 2011.

In 2020 Mr H was published. This was the first adult serious case management review held on the Isle of Man and reviewed the circumstances surrounding his eviction from his local authority flat.

In 2021 Child J was published. This review was commissioned after a child in care was admitted to hospital and nearly died as a consequence of the recreational drugs they had taken.

In October 2022 a thematic review into self-neglect was published. This was a report around 7 cases where vulnerable adults have passed away. The report can be found here and the Board's response is found here

In November 2022 a report into the circumstances about Family K that lead to the homicide of Mrs K and the serious assault of her husband, Mr K by their son Mark. The report can be found here, the Board's response here and a learning brief can be found here. 

Referrals are made by an agency that has been involved, and that agency is required to set out how the criteria for an SCMR are met on the referral form. The criteria are laid out in the Safeguarding Board Regulations 2019 and further guidance laid out in Safeguarding Together 2019. If you are thinking about submitting a referral we strongly advise that you speak to a senior person within your organisation before completing the form. The Safeguarding Board can only accept referrals which have been signed off by a senior representative from the Board organisations. For further advice please contact the Safeguarding Board business team on (01624) 687365. 

Other Reviews, Learning Reports, Audits and Action Plans

The Board also undertake a number of other learning, audits and reviews to provide assurance and assist with improving practice where necessary. The following learning reports have been presented to the Board.