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3.2 Serious Case Reviews

Please note - Under the Children and Social Work Act 2017, Serious Case Reviews will be replaced by new national and local arrangements for reviewing serious cases. Safeguarding Children Boards must continue to carry out all their statutory functions, including commissioning SCRs, until the point at which safeguarding partnership arrangements begin to operate in a local area.

This chapter is currently under review pending the introduction of safeguarding partnership arrangements across the consortium area.


1. Serious Case Review Process
  1.1 Criteria for Notifiable Incidents
  1.2 Decisions Whether to Initiate a Serious Case Review
  1.3 Methodology for Learning and Improvement
  1.4 Appointing Reviewers
  1.5 Timescale for Serious Case Review Completion
  1.6 Engagement of Organisations
  1.7 Agreeing Improvement Action
  1.8 Publication of Reports
  1.9 Considerations for Local Processes
  Further Information

1. Serious Case Review Process

1.1 Criteria for Notifiable Incidents

A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected; or
  • A Looked After Child has died (including cases where abuse or neglect is not known suspected).

The local authority should report any incident that meets the above criteria to Child Safeguarding Practice Review Panel and relevant safeguarding children partnership within 5 working days of becoming aware that the incident has occurred.

1.2 Decisions Whether to Initiate a Serious Case Review

The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 1.1, Criteria for Notifiable Incidents) for a Serious Case Review. This decision should normally be made within 1 month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).

The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCB will also want to review instances of good practice and consider how these can be shared and embedded. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review.

1.3 Methodology for Learning and Improvement

Working Together to Safeguard Children does not prescribe any particular methodology for reviews, but requires that reviews:

  • Recognise the complex circumstances in which professionals work together to safeguard children;
  • Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seek to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Are transparent about the way data is collected and analysed; and
  • Make use of relevant research and case evidence to inform the findings.

Whilst Working Together to Safeguard Children stops short of advocating any specific method,  the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

1.4 Appointing Reviewers

The LSCB will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews.

The lead reviewer should be independent of the LSCB and the organisations involved in the case.

Working Together to Safeguard Children requires that reviews of serious cases are led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.

1.5 Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

1.6 Engagement of Organisations

The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

In addition, the LSCB can require a person or body to comply with a request for information, Section 14B of the Children Act 2004.This can only take place where the information is essential to carrying out LSCB statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCBs should be mindful of the burden of requests and should explain why the information is needed.

1.7 Agreeing Improvement Action

The LSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

1.8 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the General Data Protection Regulations (GDPR), Data Protection Act 2018 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

1.9 Considerations for Local Processes

  • Engagement of families, children and service users. There is an increasing body of evidence that the family members, including children, can make a valuable contribution to professional understanding;
  • Coordination with parallel review processes (that still require formal IMR’s such as Domestic Homicide Reviews);
  • Publication in full of the Overview Report;
  • Appointment of a ‘lead reviewer’ rather than an Overview author and independent chair;
  • Auditing and monitoring of the ‘programme of action’ following the findings of the review;
  • Using tools which are suitable for inter agency auditing i.e. those which capture similar data and track evidence in a consistent way.

Further Information

NSPCC Serious Case Reviews Repository

Bradford SCB Serious Case Reviews

Calderdale SCP Serious Case Reviews and Case Reviews

Kirklees SCB Serious Case Reviews

Leeds SCP Serious Case Reviews

Wakefield & District SCB – Serious Case Reviews