Serious Case Reviews

Working Together to Safeguard Children 2015 (Chapter 4) sets out the purpose and process of Serious Case Reviews (SCR). SCR's are undertaken when a child dies (including suicide) or is seriously injured, and abuse or neglect is known or suspected to be a factor.
The purposes of SCRs carried out under this guidance are to:
  • Identify and establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;
  • Identify clearly within what timescales any improvement and learning will be acted upon, and what is expected to change as a result; and
  • Improve single agency and partnership working to better safeguard and promote the welfare of children.

Publishing of reports

Working Together 2015 states:

Publication of reports

All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.

The requirement to publish SCR reports has been in force since 2012.  Prior to that reports were confidential.

Publishing of Serious Case (SCR) and Learning Review reports

The London Borough of Southwark Safeguarding Children Board has recently published Child Y SCR Report. Southwark SCB took the lead on this Serious Case Review about a Wandsworth Child who was placed in their Borough.

Specific learning points for Wandsworth Council Children's Services:

  • As part of its matching process for potential placements professionals to complete and update when circumstances change a 'need/ risk assessments' about all children already placed with suitable alternative families (this should be informed by means of contact with at least one professional known to those children)
  • To address during at home visits and at formal statutory reviews, the lived experience of the children including their relationships with siblings/ other children and adults in their new home
  • To identify the individuals involved and take steps to disseminate to all relevant staff the regulatory requirements for nominated officer/director approval with respect to out of borough and at a distance placements respectively
  • To ensure that notification of placements to host local authorities are made and they include the child's details and Care Plan. 
  • To update local practice guidance and procedures to clarify the above expectations 

Learning from National Serious Case Reviews

The NSPCC provides series of at-a-glance briefings highlighting the learning from case reviews that are conducted when a child dies or is seriously injured, and abuse or neglect are suspected.

Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews.

You can find these briefings on the NSPCC site

Learning Lessons from Baby Eliza Serious Case Review

All Local Safeguarding Children Boards follow the statutory guidance in Working Together to Safeguard Children 2015 when considering the threshold for conducting a serious case review (SCR), This should take place if a child abuse or neglect is known, or suspected in a case and a child has died or a child has been seriously harmed and there is cause for concern about how the authority or other organisations or professionals worked together to safeguard the child. The WSCB has undertaken a Serious Case Review on Baby Eliza* in 2016-17.

The SCR was about baby Eliza who received serious injuries whilst living at home with her mother. Eliza's mother was recognized as a young parent who suffered from gendered abuse across her childhood and into adulthood; from child sexual abuse to child sexual exploitation then domestic abuse. The mother experienced separation and disrupted attachments from her family as child who moved between care arrangements in her family and was in public care as a teenager; she experienced harm/ abuse and was a missing child. In light of child protection concerns about neglect and harm to animals her first child was removed.

Her own history impacted upon her parenting capacity. Professionals worked with the family recognised their sympathy for her as a child who had been looked after and was also a vulnerable care leaver. The SCR highlighted the potential to identify with the abused child within the adult who was a parent. The possibility that practitioners may have over identified and whether this unconsciously impacted on decision making and response to concerns was noted. Professionals initiative to ask questions and show curiosity about the role of men and fathers; their history of parenting and relationships was also raised. 

What was learnt from the SCR? The WSCB recognised the learning highlighted in this SCR as listed below: 

  • Pre-Birth Assessment Guidance was revised and reissued to ensure that pre-birth procedures are understood & followed.
  • Information sharing should be prioritised by all agencies to ensure the welfare of the baby. 
  • Importance of detailed safeguarding information being included in referrals for services to help identify the child needs. 
  • A recognition that mental ill-health, substance misuse and domestic abuse have an impact on capacity to parent to inform a risk assessment for a vulnerable child and not diminished in consequence of sympathy for a vulnerable parent. 
  • The benefit of precision in professional exchanges e.g. status of a service user's given address and commonality of terms (core group v team around the child). The WSCB has now changed the terminology and asked professionals to use the term Core Group in line with the Child Protection Procedures. 
  • The WSCB will need to continue to hold professionals and organisations to account to support them to challenge perceived errors of professional judgments. 
  • Professionals will need to continue to encourage full involvement of GPs.

Guidance for the Rapid Review Process 2019

Rapid reviews are held to assist the Safeguarding Children Board/ Partnership in deciding whether to convene a Serious Case Review or alternative learning review as per the new Working Together 2018. 

View full guidance for Rapid Review Process.

Useful links

Social Care Institute for Excellence

Information on Serious Case Reviews