Due to the Covid-19 crisis the National Safeguarding Panel did not hold its usual meeting in May, instead using the Zoom meeting app we met for 90 minutes with members of the National Safeguarding Team (NST). Our focus was a consultation presented by the NST on proposed new guidance for reviews of major cases. These reviews are commissioned by the Church to understand what happened in relation to safeguarding failures in order to learn lessons for the future. A draft document had been circulated and a structured conversation took place to gain the thoughts and views of Panel members. Others within the Church are also being consulted before a final draft will be presented for considered for approval by the National Safeguarding Steering Group.

A lot of ground was covered during the 90 minutes and this blog sets out key issues.

Previously guidance on reviews had been included within other documents.  A decision has been made to issue stand-alone guidance with the aim of making it relevant to all contexts. The intention is to have separate guidance for national and local practice and procedure.


It is important to get the process of reviews right. This includes how to request a review, who commissions it, how the terms of reference are developed, oversight during the review and ensuring that outcomes are acted upon. It was suggested that a flow chart would be a useful addition instead of just relying on the text. It was felt that definitions needed to be tightened as to some people a review might suggest that decisions made could be changed, rather than the focus being to learn lessons. Timescales need to take account of the expected complexity and scale of the review.

There need to be clear criteria for publication. As reviews contain a lot of sensitive information it is important that the redaction process is done ethically and with much care and attention.

The guidance should include a section on governance to explain how the review should be conducted and how the reviewer is held to account. There should be clarity about what happens at the end of the review, including how to embed recommendations into practice.

Involving and Supporting Victims and Survivors
There should be an explicit requirement to consult victims and survivors of the case concerned, before starting any review to ensure they have confidence in the process. This should include matters of content and terms of reference. Giving victims and survivors an opportunity to comment on reviewers is important but the reasons for doing so need to be clear. For instance, it may avoid conflicts of interest or prior knowledge of the case by the reviewer. There should be a recognition that a review may not address some important issues for survivors such as redress and apology. There needs to be honesty about the scope of a review. Some Panel members felt that survivors generally want reviews to get to the truth, while getting ‘justice’ is often a separate issue for them.

It was suggested that there needs to be an assessment of victim and survivor needs, with the review being an opportunity for healing. The draft guidance did not consider the involvement of children or young people. Children should have equal access to such healing if it can be managed appropriately with the support of a parent or guardian.

Good engagement between the reviewer and victims and survivors can be critical to achieving the best outcome. Clear timescales are particularly important. There should be updates on progress, especially if there is any delay. If after completion of a review, there is survivor dissatisfaction there needs to be a mechanism for a response.

Reviewers need to be independent of the Church. There should be a focus on the skills and experience required by reviewers rather than assuming that they must have a particular professional qualification. It is important that they know the right questions to ask and avoid assumptions.

One of the issues affecting timescales is the length of time it can take to locate an appropriate reviewer. Once a person is identified there can then be an issue of their availability. It was suggested that there could be a process to identify potential reviewers to ensure suitable people are ready to be approached when needed. 

Learning lessons
There was agreement that the emphasis is on lesson learning, and this should be made clear to all concerned. The approach should not be punitive but focus on improving practice. This means avoiding blame, recognising any structural issues as well as the actions of individuals. It is important that nothing is hidden and there is admission of errors and faults. Policy does need to recognise that the Church has to hold individuals to account for their actions and to be clear how the review process fits with discipline measures. A question is whether harm could have been prevented or mitigated? It can be easy to use hindsight and not recognise the issues faced at the time.

It is crucial that all involved are asked the right questions, particularly frontline staff and those involved at crucial points. This is fundamental to taking a more in depth, systemic approach to learning lessons as their perspectives provide understanding of the context.

National and local approaches need to be linked. There should be a process to collate all of the lessons learnt and a system to ensure that they are embedded in policy and practice. It is essential that the whole Church can learn from the process to avoid repeating errors in different places. There is a need for simple way to share learning. It would be helpful to have case review briefings with a summary of risk factors and learning for improved practice around the issues.

There needs to be recognition that implementing recommendations requires systemic change to be effective. People need opportunity to discuss and reflect, and crucially to be asked how it applies to them and what they will do differently as a result. This has to be done strategically and systematically.

Overall Panel members and National Safeguarding Team staff considered that the online consultation format had worked well. This will allow us to be consulted more regularly in a similar manner on other policy developments in addition to the Panel meetings. 

Next meeting
At the July meeting the Panel will consider the issue of redress, which arises out of the debate on safeguarding at Synod earlier this year. If it is not possible to meet in person it will be held via Zoom.