The Care Inspectorate has today published a report on Criminal Justice Social Work Serious Incident Reviews.

Serious Incident Reviews are carried out by local authority criminal justice social work services to make sure lessons are learned if things go wrong when an offender is on licence or some other form of supervision. The report has highlighted areas of successful good practice across Scotland, but also made recommendations where further improvements should be made. 

The report covers 111 serious incident notifications between June 2013 and January 2015, of which 80 serious incident reviews have been completed. These serious incidents took place across 24 of Scotland’s local authorities. The serious incidents include drug overdoses, sexual offences, suicide, terrorism offences, culpable homicide and murder.

Karen Reid, chief executive of the Care Inspectorate said: “Where an offender is on licence or some form of supervision, there is – rightly – intense public interest in how they are supervised. 

“Effective community justice social work can and should prevent re-offending and support offenders to live a life free from crime. When things do go wrong, it is essential that the right lessons are learnt by people across Scotland. Our independent scrutiny of serious incidents and how they were handled is essential to driving up quality and improving public protection. 

“If a serious incident occurs, it is always important to consider whether things might have been done better or differently. We are today making a number of recommendations for local authorities.

“While there is some excellent practice, there needs to be more robust risk assessment and planning when prisoners are preparing for release. We previously found under-reporting of serious incidents. It is critical that serious incidents are reported and reviewed properly and that all criminal justice staff understand and follow the procedures to make sure our communities are as safe as they can be.”

Today’s report notes that that there has been a readiness and openness by most local authorities to undertake comprehensive, detailed reviews to take a closer look at practice and management arrangements in serious cases. There has also been an improvement in local authorities complying with the reporting arrangements and carrying our Serious Incident Reviews when they should. Undertaking these reviews allows local authorities to identify where improvements can be made and put actions in place. This should drive up standards of practice and ensure robust approaches to managing offenders and keeping communities safer.

The report highlights the importance of robust risk assessments for offenders. This helps identify areas that require specific attention, so specific behaviours can be targeted. The Care Inspectorate has called for assessments to be completed more quickly and to better inform plans for managing offenders and making communities safer, especially at the point prisoners are preparing for release.

The report identifies the need for strong partnership working and good communication to keep people safe, address offending behaviour and support offenders’ needs. When an offender does not comply with the conditions of their order, firm action is needed to try and minimise the potential risk to communities.

The Care Inspectorate will continue to monitor notifications and reviews within each local authority through the lead officer for Serious Incident Reviews, and through our strategic link inspectors who have on-going contact with senior managers in local authorities. We will report again in two years of progress in this area.

The report has also made six recommendations for improvements.


  1. Continuing from the recommendation made in the last Serious Incident Review report in 2013, all local authorities need to ensure all relevant staff across their criminal justice service are aware of, and confident in applying, the Serious Incident Review guidance and are applying this effectively
  2. Some senior managers and chief social work officers need to ensure there are robust quality assurance processes in place to ensure reviews sent to the Care Inspectorate are to an acceptable standard and cover all key and critical areas. This should include attention to ensuring objective measures are in place
  3. Further action needs to be taken by senior managers to ensure that the Level of Service Case Management Inventory (the national assessment tool used by criminal justice social workers to help consider risk and needs of people who offend,) is being completed on prisoners preparing for release and is exported to community social work staff timeously to inform planning.
  4. Where staffing issues are factors in preventing the delivery of effective and efficient services in supervising offenders, managers must ensure contingency arrangements are in place
  5. Those undertaking Serious Incident Reviews should, consider and include in the review, whether the review of the licence/order in line with National Objectives and Standards is taking place and is effective in its purpose
  6. Local authorities must improve their performance in notifying the Care Inspectorate within five working days of a serious incident occurring.

There are three general circumstances when a serious incident review should be carried out.

First, an offender on supervision or licence may be charged with carrying out a criminal offence which results in death or serious harm to someone else.

Second, there may be significant concerns about the way such an offender is being supervised.

Third, it may be that an offender on supervision has died or been seriously injured in a circumstance likely to generate significant public concern.

Each time a serious incident occurs local authorities must notify the Care Inspectorate within five working days, and that information is quickly shared with the Scottish Government. The local authority is then required to review the incident and the Care Inspectorate’s job is to scrutinise, and comment on, the local authority review.

The full report is available here