Families SA Adverse Events Review Committee

In reply to Ms CHAPMAN (Bragg—Deputy Leader of the Opposition) (8 May 2014).

The Hon. J.M. RANKINE (Wright—Minister for Education and Child Development): I have been advised:

In 2004, Families SA consolidated and formalised its system for undertaking reviews of the deaths and serious injuries of children who have been involved with Families SA. This resulted in the establishment of the Adverse Events program and the Adverse Events Committee.

What has remained consistent since 2004 is the strong focus on practice reforms. The Adverse Events process aims to provide staff with practice knowledge and tools that enable Families SA to provide the best possible service to vulnerable children, young people and their families.

An important part of the committee's influence on Families SA practice environment is its capacity to make recommendations to Families SA Executive for change at an agency level. The committee is formally a subcommittee of Families SA Executive which emphasises this direct link with Families SA decision-making and practice implementation.

The Adverse Events program has established vital working relationships with external review bodies such as the Child Death and Serious Injury Review Committee (CDSIRC) and the Coroner. Findings and recommendations from such bodies are considered and progressed by the Adverse Events Committee, noting quite often the similarity of themes that subsequently influence Families SA practice and policy implementations.

Since the establishment of the Adverse Events Committee in 2004, almost 70 Adverse Event Reviews have been conducted with respect to 93 children/young people. Each review report is considered by Adverse Events Committee and contains recommendations and/or findings that relate to the case and wider practice issues, where appropriate. Such findings and recommendations recognise both exemplary practices by Families SA and essential learning's with respect to continuous improvement.

Families SA Executive generally accepts and progresses implementation of recommendations. Examples of recommendations that have contributed to the implementation of practice changes include:

the infant safe sleeping guidelines;

establishment of high risk infant policy and procedural guidance;

establishment of key principles for working with culturally and linguistically diverse families;

establishment of the Senior Practitioner review to consider the mentoring and quality assurance role of social workers to positively influence practice and family assessments;

the establishment of the protocol for the conduct of interviews with interpreters; and

the establishment of the interagency memorandum of understanding relating to chronic school non-attendance.

In 2014 and 2015 the Adverse Events program will continue to focus on learning and development to capitalise on the recommendations and learnings from internal and external review processes to promote continuous improvement mechanisms.