This chapter was added to the APPP in May 2021.

1. Scope

This guidance applies within Hull City Council Adult Social Care, to be used when the investigation into a serious incident requires an Individual Management Review (IMR) be carried out. Not every investigation into a serious incident will require an IMR, and some investigations may require several IMRs to be carried out if different agencies or partners have been involved.  Partners or other agencies may have their own IMR guidance, or they may choose to adopt this guidance.

2. What is an Individual Management Review?

An IMR is a process which produces a report detailing, analysing and reflecting on the actions, decisions, missed opportunities and areas of good practice within the individual organisation. The IMR process is not designed for identifying gaps in the actions / activities of other organisations. The aim of IMR’s should be to look openly and critically at individual and organisational practice and at the context within which people were working. The purpose of the IMR is to see whether the case indicates that changes could or should be made and, if so, to identify how those changes will be brought about.

3. When should an IMR be carried out?

An IMR should always be carried out when a serious incident has resulted in death, serious harm, abuse or neglect of someone who receives ASC support and there are concerns that the actions of HCC staff may have contributed to or failed to prevent this. An IMR may also be requested, at the discretion of a head of service where a serious incident resulted in the serious risk of any of the above or any other serious incident where the head of service believes there are lessons to be learned to reduce risk in the future.

4. Who should carry out an IMR?

The person identified to carry out an agency’s IMR must have an appropriate level of experience and authority and must not have had direct involvement in the management of the situation under consideration.

5. Principles

Individual Management Reviews should be:

  • systematic: the IMR should follow the process set out in this guidance;
  • proportionate: some IMRs will only be required to focus on the incident itself and the people directly involved. However, where organisational errors, failings or abuse appear to have contributed to the serious incident, the IMR may cover a wider scope. The scope should be agreed between the person requesting the IMR and the person carrying it out at the outset, and may be revised if information subsequently comes to light which suggests a wider scope may be warranted;
  • independent: the person carrying out the review must have had no direct involvement in the serious incident under investigation;
  • transparent: the person requesting the review should inform the manager of any service or team which comes within the scope of the review that an IMR will be carried out and the person carrying out the review should be honest and open about their role. However, on no account should anyone involved in the IMR speak to the press. Any queries should be directed to the press officer. Following the review, the findings should be shared with the people or teams within the scope by the head of service or their delegated nominee. The findings should also be shared with the service users affected by the incident which triggered the IMR and with any family members, friends or carers involved in the incident, in managing or responding to the incident, in supporting the person following the incident or in the IMR process. If the service user consents, information can be shared with other family members, friends, carers or anyone with an interest in their welfare. If the person has the capacity to give or withhold consent and does not consent, this must be respected. If the person does not have capacity to give or withhold consent, a decision on what information should be shared with family or friends not involved in the incident or the IMR process must be made in their best interests.

6. Process

When undertaking an IMR the following process should be followed:

  • the person requesting the IMR and the person carrying it out must agree the scope – who and what will be covered by the IMR. They should agree a timescale which contains target dates for completion, submission of the report to the head of service and consideration of the findings, recommendations and action plan by DMT. The person carrying it out must then:
    • establish and record a chronology of events;
    • collate information from written records;
    • interview key people involved in the incident or incidents where needed. Not every IMR will need interviews to be completed; some will only require a desktop review of the records and this should be agreed in the scope;
    • analyse the events as they unfolded. With hindsight, what could have been done differently which may have improved the outcome?
    • identify findings and recommendations;
    • write a report and submit it.

7. The Report

7.1 Methodology

This should detail how the IMR was carried out and should reflect the scope. Where interviews took place, it should list who was interviewed and why those people were selected. Anonymised references should be used with a key provided as an appendix. For example, the report may refer to SW1, SW2 or GP. Names and contact details may be provided in the appendix. All documents used during the review should be listed.

7.2 Body of the report

This should include a narrative overview supported by a chronology.

Consideration should be given to the terms of reference of the serious case review when completing the report.

Briefly outline the events that occurred, the decisions made, and the actions taken or not taken. Try to provide an explanation not only of what happened but why.

Consider whether there are lessons from this case for the way in which the individuals, teams and organisations involved work? Is there good practice to highlight, as well as ways in which practice or methodology can be improved? Are there implications for ways of working; training, management and supervision; working in partnership with other organisations.

Are there any specific messages regarding how resources were used?

7.3 Recommendations

The recommendations should show a clear link between the evidence collated during the review which is detailed in the report and a reasonable analysis of that evidence. Recommendations may refer to a specific SMART action or may require a further process is initiated and followed, for example, a workforce development response when there are lessons learned from good practice or from what went wrong which the wider organisation would benefit from.

7.4 Action plan

This should build upon the recommendations and set out what action should be taken by whom and when? It should specify the intended outcomes of the actions, and set out how the organisation will evaluate whether they have been achieved?

8. After the IMR is Complete

8.1 Submitting the report

After the IMR is complete, the report, containing the recommendations and action plan should be submitted to the person or group (eg DMT) who requested the IMR within the timescale agreed. The person or group should discuss the report with the investigating officer to identify and agree any further recommendations or lessons learned which may become apparent.

8.2 Consideration by DMT

If the IMR has been requested by a HoS, and not DMT, the HoS should submit the IMR report to DMT for consideration and agreement to any recommendations or actions which resource or organisational implications. DMT should consider these in light of previous IMR findings – if mistakes of the past have been repeated, different actions may be needed to learn the lessons and ensure there is no further repeat. If far reaching or complex actions are needed, or if actions require a joint response with partners, DMT should consider whether individuals should be charged with implementing actions or whether a task and finish group should be set up to deliver improvement.

8.3 Implementing the action plan

DMT should consider and authorise the implementation of the action plan and may place the responsibility for implementing different actions on different officers. For example, one officer may be charged with implementing practice changes while another takes responsibility for workforce development or commissioning issues. DMT should agree a date for the action plan implementation to be reviewed, and set out how it will be reviewed. This will differ depending on the complexity of the action plan and may require a report to be submitted by a named person or a series of reports by different people. If a task and finish group has been set up, DMT may require regular progress reports.

8.4 After the action plan has been implemented

Once the action plan has been implemented, a final report should be prepared and submitted to DMT. This should provide an analysis of whether the actions have been effective in delivering sufficient improvement or reducing risk and may recommend further actions if necessary. As part of the preparation of the final report, the outcomes of the agreed actions should be discussed with the service users affected by the incident which triggered the IMR and with any family members, friends or carers involved in the incident, in managing or responding to the incident, in supporting the person following the incident or in the IMR process. Their views on the sufficiency of the improvement or risk reduction should be included in the final report.

The final report should be shared with DMT and with the workforce group so that any themes or other workforce development implications can be recognised and responded to.