How Sequeli began

Sequeli began, not with training for chairs, reviewers or commissioners but with an observation about recommendations and their implementation. In 2006 following publication of a mental health investigation, the Independent Inquiry into the Care and Treatment of MN, there was, unusually, a two year published follow-up by the inquiry team to establish whether recommendations had been implemented. In the course of this it became apparent that recommendations could be categorised according to complexity and difficulty of implementation. Moreover, analysed like this, mental health homicide investigations were similar to those of serious case reviews and domestic homicide reviews. As a result, a paper Learning Lessons: Using Inquiries for Change by Gillian Downham and Richard Lingham, published in the Journal of Mental Health Law in Spring 2009 proposed a shared methodology for implementation of recommendations across serious case reviews, mental health investigations and domestic homicide reviews.

It was a logical next step to apply the same integrated approach to training of chairs and report writers.

The crossover between training for mental health investigations and children's serious case reviews was made in June 2009 at a Dartington Social Research Unit seminar. Inclusion of domestic homicide reviews came as Gillian Downham was a member of a Home Office Working Group looking at developing guidance for statutory domestic homicide reviews (implemented in April 2011). Training for vulnerable adults' serious case reviews were included following discussion with Professor Jill Manthorpe at King's College, who is an authority in this field.

Before the Core Competencies

The forerunner of the Core Competencies, A Scoping Paper for the Development of a Training Curriculum for Chairs and Report writers of Serious Case Reviews, Mental Health Investigations and Domestic Homicide Reviews, was written by Gillian Downham and Wendy Rose in October 2009.

It received strong support from key national organisations when it was presented at a unique cross-agency national seminar held in October 2009, organised by Gillian Downham, Roger Bullock and Wendy Rose. Those attending the seminar included individuals from the following organisations:

Independent Police Complaints Commission, Metropolitan Police Violent Crime Directorate Community Safety Unit, Independent Advisory Panel on Deaths in Custody, Home Office Interpersonal Violence Team, Department of Children, Schools and Families National Safeguarding Delivery Unit, Ofsted, NSPCC, University of Edinburgh NSPCC Centre for UK-wide Learning in Child Protection, Care Quality Commission, National Patient Safety Agency, Department of Forensic Psychiatry Broadmoor Hospital, Department of Health Inquiries Section, Sainsbury Centre for Mental Health, University of East Anglia Social Work Department.

In November 2009 the idea of a unified training curriculum based on the Scoping Paper received further strong support at a high level summit Learning from SUIs and independent investigations in mental health and learning disabilities: a better way forward? organised jointly by the Care Quality Commission, National Patient Safety Agency, The NHS Confederation, The National Mental Health Development Unit and Leeds Partnerships NHS Foundation Trust.

The Core Competencies document written in October 2010 and revised periodically since then by Gillian Downham and Wendy Rose is still based on the original core knowedge and skills identified in the Scoping Paper.

Linking with the present

The inspiration existing at the start of Sequeli has not only remained, but flourished.

Although each type of review remains bound by its own national guidance - some of them very different to each other - it has become increasingly evident that in practice the methodologies of children's serious case reviews, safeguarding adults reviews, domestic homicide reviews and mental health investigations have much in common.

The Home Office and Department for Education have acknowledged this through their adoption of training materials based on Sequeli's System, using principles, knowledge and skills which cut right across Departmental boundaries.

Try taking a look at the paper Using Inquiries for Change (see opposite) which has seen continued life in the form of Sequeli's Learning from reviews and investigations which is part of Sequeli's System and which has also formed part of the training materials created by Sequeli for the Department for Education (look for page 70).








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