Reporting
Section 27 – Reports on case reviews: content and preparation
221.This section makes provision about the report which must, under subsection (1), be prepared by a case review panel at the conclusion of its review. This provision therefore would not apply if a review was discontinued mid-way as a result of the exercise of the Lord Advocate’s power to order discontinuation of a review under section 23(2). While it is for the case review panel as a whole to prepare the report, the intention is not that the report will be “drafted by committee” – it will be for the case review panel chair to draft the report which will be endorsed by the panel as a whole. Should a case review panel chair be unable to draft the report, those providing administrative support will in practice be able to prepare the report for endorsement by the panel.
222.There are certain things which must, under subsection (2), be included in a report, but it is open to the panel to include such other information as it sees fit. The things which must be included are—
a timeline of what the panel considers to be any key events prior to the death,
where persons A and B were partners/ex-partners, a summary of the significant relationships they had at the time of the death, and a summary of any changes in such relationships in the period leading up to the death,
information about any opportunities for intervention which were either missed or taken,
the panel’s conclusions,
its reasons for reaching those conclusions, and
any recommendations it has as a result.
223.What the panel considers to be key events will vary from case to case but these do not have to be something momentous. For example, this could include events which might seem relatively innocuous in themselves but in the context of other evidence take on a greater weight (for example, the first of a series of missed appointments with healthcare or social services after a pattern of regular attendance). The dates of these events will be important in the context of the review because of their role in establishing things such as whether a victim had already been identified as a potential victim of abusive behaviour by the time of a particular incident, or whether there had been a series of events over an extended period which should have been a warning of possible difficulties.
224.If the report is not one that is agreed upon by the panel members unanimously, the points of disagreement must be reasonably reflected (see subsection (3)).
225.The review oversight committee’s general duty under section 22(6) to ensure that any case review panel appointed to carry out a review makes satisfactory progress in doing so will apply to the production of a report just as it applies to the review itself. It will consider whether a report is of satisfactory quality overall, as well as whether the review’s terms of reference have been fulfilled.
226.Once a report is prepared, the chair of the panel has to submit it to the review oversight committee for approval under subsection (4). Subsection (5) then provides for the committee to decide whether modifications are required before approving it. If they are required, the committee will be able to decide whether to make these itself (which may be possible in, for example, the case of minor corrections) or whether to direct the panel chair to resubmit an amended report (for example, because the information that is missing is not within the committee’s knowledge). Where a report is resubmitted, subsection (6) ensures that the same process of approval with or without modifications, or a further direction to make changes, can occur.
227.Subsection (7) provides that the chair of the panel and the chair of the review oversight committee are each entitled to share a draft report (or part of it) with any person with whom they consider it appropriate to share it for the purpose of checking its accuracy. There is no restriction upon the timing of when this is done (other than that the report still has to be in draft) but in practice when material is being shared for this purpose by the chair of the panel then the expectation is that they would normally do so prior to submitting the report to the review oversight committee for approval. However, one exception to this might be where, following submission to the committee, the panel chair is directed to resubmit the report with some changes and the panel chair wishes to fact-check an aspect of the new material before adding it. Subsection (8) makes further provision about any such sharing—
It obliges the person who is deciding whether or not to share the report/extract to take that decision in accordance with the protocol (see section 24 and paragraphs 208 to 211 of these Notes). Any sharing itself must also accord with the protocol. This applies regardless of whether the person taking the decision is a party to the protocol.
It provides that the person sharing the material can redact or anonymise it as appropriate. This goes further than the ability to share a part or parts (i.e. extracts): the changes could include adding in pseudonyms or making some details vaguer rather than simply omitting them. The person sharing the material must also, at the same time, provide the Scottish Ministers with a copy of the material that is shared.
It provides that the person with whom the material is shared may not share it with anyone else and must keep the content confidential, unless and until the information is subsequently published. As such, if an individual within an organisation needed to share it with someone else within their organisation in order to confirm the accuracy of the report, they would need to ask the chair of the panel or committee to share it with that person directly rather than doing so themselves. It should be noted that the term “person” here covers organisations as well as individuals (see schedule 1 of the Interpretation and Legislative Reform (Scotland) Act 2010).
228.Once a report has been approved, the committee must, under subsection (9), provide a copy of it to the Scottish Ministers. Where the report relates to the death of a young person or an adult at risk, the committee must also provide a copy of it to Social Care and Social Work Improvement Scotland.
229.Subsection (10) gives the Scottish Ministers a regulation-making power (subject to the affirmative procedure) to make provision about the resolution of any disputes which arise between the chair of a panel and the review oversight committee in respect of any modifications which the committee proposes to make to a report or any direction it gives requiring resubmission of a report. This mechanism could be used to provide for Ministers themselves to resolve the matter, to provide for someone appointed by Ministers to provide the resolution, or to make provision allowing the parties themselves to resolve the matter.
Section 28 – Reports on case reviews: publication and sharing
230.Following a report being finalised and approved under section 27(5), the committee can also, under subsection (1) of this section, choose to publish a report (or part of it) – but only where consent has been given by the Lord Advocate. However, in every case, the committee has to publish (either in the report if it is published, or separately) such information as it considers appropriate about the recommendations made in the report.
231.Subsection (2) requires the chair of the review oversight committee to take all reasonable steps to ensure that any published reports do not include information which would or might identify specified individuals (either directly, or through information which could reasonably allow “jigsaw identification”). This rule applies regardless of whether the individual concerned has participated in the review process and regardless of whether the individual is living or dead. The individuals whose identities are protected by this rule are—
the person whose death is the subject of the review or who is person A or person B in relation to the death in question (normally the person whose death is being reviewed will be person A or person B, but the person who has died is named separately because this will not be the case where there is the death of a connected young person),
any individual who is or was connected with any of the individuals mentioned immediately above (for example, as a family member, friend or acquaintance),
any individual who was involved in events which were examined by the review (for example, a social worker, doctor or police officer who had an interaction with the victim following an assault).
232.Those who are not therefore covered by the rule above and who could be identified in the report – if that was considered appropriate – would include the panel members who carried out the review and those who gave evidence to the committee but had no personal connection (for example, an unconnected social worker who gave evidence about standard social work protocols).
233.Subsection (3) allows the chair of the review oversight committee and the Scottish Ministers to each share approved reports (or extracts from them) with any person with whom they consider it appropriate to share it for the purpose of promoting the learning of lessons with a view to safeguarding those affected by abusive domestic behaviour or promoting the wellbeing of victims of abusive domestic behaviour. For example, this would allow valuable learning material which is too sensitive to be published to be shared with an organisation which is involved in tackling domestic abuse and would therefore benefit from being aware of a particular learning point. Subsection (4) makes further provision about any such sharing—
It obliges the person who is deciding whether or not to share the report/extract to take that decision in accordance with the protocol (see section 24 and paragraphs 208 to 211 of these Notes). Any sharing itself must also accord with the protocol.
It provides that the person sharing the material can redact or anonymise it as appropriate. This goes further than the ability to share a part or parts (i.e. extracts): the changes could include adding in pseudonyms or making some details vaguer rather than simply omitting them.
It provides that the person with whom the material is shared may not share any unpublished material with anyone else and must keep the content confidential.
Section 29 – Requirement to respond to report recommendations
234.This section allows for the imposition of a requirement on a person to respond to the recommendations made in a case review report. This requirement is imposed by a statement being made in a report approved under section 27(5) that a person is required to provide a response. Given the role of the case review panel and the review oversight committee in the report being prepared and approved, such a requirement could therefore be imposed by either of them but if it is imposed by the panel then it would require the consent of the committee in order to remain in the report which is approved.
235.Where a requirement is imposed, the review oversight committee must give the person a copy of the report so that the person is able to give a meaningful and informed response. The person must then, within such reasonable period as the committee specifies, provide the committee and the Scottish Ministers with a statement in response. That statement must set out what the person has done, or proposes to do, to give effect to the recommendation, and to the extent that the person does not intend to give effect to the recommendation then the statement must give the person’s reasons for that.
236.The review oversight committee and the Scottish Ministers are both empowered under subsection (3) to publish (fully or partially) the person’s written statement, and to publicise any failure to comply with a requirement to respond.
Section 30 – Periodic reports
237.Subsection (1) of this section provides for the Scottish Ministers to prepare and publish, as soon as reasonably practicable after the end of a reporting period, a report in respect of domestic homicide or suicide reviews during the reporting period. This report must also be laid before the Parliament within the same timeframe. The first reporting period will end 2 years after the day on which the definition of the review model comes into force, and thereafter each subsequent two-year period will be a reporting period.
238.There are a number of things which the report must cover under subsection (2), although it can also include such other information in respect of reviews during the period as the Scottish Ministers see fit.
239.Specifically, the report must include—
information about any common themes emerging from the outcome of reviews,
information about any lessons to be learned which are identified in case reports and which the Scottish Ministers consider to be of particular importance (for example, this might include pertinent points learned about the experiences of a particular minority group which may be of wider relevance but might not be a common theme as there may be only one report relating to that minority group),
information about any actions taken as a result of recommendations made in individual case reports and, where known, the impact of those actions,
the reasons for any cases being sifted out – e.g. where the outcome of the sift stage is a determination that a death is not reviewable or that, although it is reviewable, a review is not to be carried out (for example, it may be that a death is not reviewed because the connection with Scotland is too peripheral for there to be any lessons to be learned for Scottish systems),
the number of notices given by the Lord Advocate which suspend, discontinue or allow the resumption of a review, along with the reasons given for any suspension or discontinuation, and
certain statistical information, as set out in subsection (2)(b), which will provide an overall picture of the work taking place throughout the reporting period in respect of the review model.
240.Subsection (3) requires the Scottish Ministers to consult the persons specified in this provision when preparing a report.
