Serious Case Reviews (SCRs)

Navigation menu list for sections above the current page: Home; NSPCC inform

Research, statistics and information: Research reports; Statistics; Factsheets and FAQs; Briefings; Reading lists; Directories; NSPCC Research Department; NSPCC Information Service

Serious Case Reviews (SCRs)

NSPCC factsheet

March 2010

Our factsheet explains why serious case reviews are carried out and who undertakes them. It also describes what happens during and after the review process.

When is a Serious Case Review undertaken?
Is the term ‘Serious Case Review’ used across the UK?
What is the purpose of a Serious Case Review?
Who undertakes a Serious Case Review?
What happens during a Serious Case Review?
What happens after a Serious Case Review?

When is a Serious Case Review undertaken?

The criteria for carrying out a Serious Case Review (SCR) are contained in Chapter 8 of the Government's Working together to safeguard children guidance (2010)¹. This chapter was updated in December 2009 to reflect Lord Laming's recommendations on SCRs and the outcomes of the recent public consultation.

The guidance states that a SCR should always be undertaken when a child dies (including suicide), and abuse or neglect is known or suspected to be a factor. It should also be carried out when a child dies in custody (in police custody, on remand or following sentencing), in a Youth Offending Institution (YOI), or a Secure Training Centre (STC), or where the child was detained under the Mental Health Act 2005 (para 8.9).

A SCR should be considered when:

“a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; or
a child has been seriously harmed as a result of being subjected to sexual abuse; or
a parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004,²
a child has been seriously harmed following a violent assault perpetrated by another child or an adult,

and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children” (para 8.11).

Since April 2007, local authorities are required to notify Ofsted of all incidents involving children that are serious enough that they may lead to a serious case review, including where a child has died or suffered significant harm as a result of abuse or neglect, or that have attracted national media attention.³

According to the Working together guidance,¹ the Chair of the Local Safeguarding Children Board should consider whether a case might meet the criteria for a SCR and should notify Ofsted of the decision on whether or not to carry out a serious case review. Ofsted will then pass this information to the relevant Government Office (GO) and the Department for Children, Schools and Families (DCSF) (paras 8.17 and 8.18).

References

1. HM Government (2009) Chapter 8. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: Department for Children Schools and Families (DCSF).

2. Great Britain, laws and statutes (2004) Domestic Violence, Crime and Victims Act 2004. Norwich: TSO.

3. Gilbert, Christine et al (2008) Safeguarding children 2008: the third joint chief inspectors' report on arrangements to safeguard children. London: OFSTED. Paragraph 289.

Related link

Brandon, Marian et al (2009) Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005-2007 (PDF). London: Department for Children, Schools and Families (DCSF).

Is the term ‘Serious Case Review’ used across the UK?

The term 'Serious Case Review' is only used in England and Wales.^4,5 In Northern Ireland, Area Child Protection Committees are required to undertake Case Management Reviews⁶ and in Scotland, Child Protection Committees conduct Significant Case Reviews.⁷

References

4. Vincent, Sharon (2009) Child death and serious case review processes in the UK (PDF). Briefing paper no. 5. Edinburgh: The University of Edinburgh/NSPCC Centre for UK-wide Learning in Child Protection.

5. Welsh Assembly Government (2006) Chapter 10 (DOC). In: Safeguarding children: working together under the Children Act 2004 . Cardiff: Welsh Assembly Government, 2006.

6. DHSSPS (2003) Co-operating to safeguard children. Chapter 10: Case Management Reviews (PDF). Belfast: Department of Health, Social Services and Public Safety, 2003.

7. Scottish Executive (2007) Protecting children and young people: interim guidance for Child Protection Committees for conducting a Significant Case Review (PDF). Scottish Executive, Edinburgh.

What is the purpose of a Serious Case Review?

Serious case reviews are not inquiries into how a child died or who is culpable; these are matters for coroners and the criminal courts, respectively (Working together to safeguard children, HM Government, 2006,⁸ para 8.7).

The purpose of a Serious Case Review is to:

“establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children
identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and
improve intra- and inter-agency working and better safeguard and promote the welfare of children” (para 8.5).

Reference

8. HM Government (2009) Chapter 8. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: Department for Children Schools and Families (DCSF).

Related link

Child homicides
NSPCC statistics.

Who undertakes a Serious Case Review?

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006⁹ requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases (para 5.1e). LSCBs are inter-agency forums, set up by a local authority, to agree how different agencies and professionals should co-operate to safeguard children.¹⁰

The appropriate regional Government Office Children and Learners Team will be able to assist LSCBs where policy advice on undertaking a SCR is required (Working together to safeguard children, ¹¹ para 8.20).

In cases that do not meet the criteria for a full serious case review, the Working together guidance suggests conducting individual management reviews or a smaller-scale audit of individual cases (para 8.17).

In cases that do meet the criteria, the LSCB establishes a Serious Case Review Panel involving local authority children’s care, health services, education and the police at a minimum as well as any other relevant agencies (paras 8.14 and 8.15).

The decision to conduct a SCR must be made within one month of the LSCB chair being made aware of the incident and should be completed within six months, unless an alternative timescale is agreed with the relevant Government Office (paras 8.22 and 8.23).

References

9. HM Government. The Local Safeguarding Children Boards Regulations 2006. Statutory Instrument no. 2006/90. London:TSO.

10. HM Government (2006) Chapter 3. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Norwich: TSO.

11. HM Government (2010) Chapter 8. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: Department for Children Schools and Families (DCSF).

Related links

What happens during a Serious Case Review?

Working together to safeguard children (HM Government, 2010)¹² states that each of the relevant services identified in the initial scoping of the review is required to undertake an individual management review of its involvement with the child and the child’s family (paras 8.28 and 8.29). The aim of an individual management reviews is for an agency to critically assess practices, and identify how any improvements can be made (para 8.35).

The SCR Panel will commission an independent overview report, which brings together and analyses findings from all of the individual management reviews and makes recommendations for future action (paras 8.32 and 8.40). Although acting independently, report authors tend to confine themselves to procedural and process issues, particularly when making recommendations.¹³

The SCR Panel should ensure that all contributing organisations and individuals are satisfied that their information is fully and fairly represented and that any findings from other relevant processes such as care or criminal proceedings, an inquest or inquiry/investigation are incorporated into the overview report (para 8.41).

The SCR Sub-Committee will also need to look at how the child (where the review does not involve a death), surviving siblings, parents or other family members should contribute to the review and who should facilitate their involvement (para 8.20).

References

12. HM Government (2010) Chapter 8. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: Department for Children Schools and Families (DCSF).

13. Dunstall, Sue (2008) Child death investigation and review (PDF, 76KB) NSPCC Policy Summary. London: NSPCC. (Footnote 7).

What happens after a Serious Case Review?

Working together to safeguard children (HM Government, 2010)¹⁴ states that the SCR Panel should translate recommendations into an action plan and the senior manager in each of the organisations which will be involved in implementing the action plan should sign up to this plan (para 8.41).

A copy of the executive summary which accurately reflects the full overview report must be made publicly available (para 8.42), which may be through the local authority’s website.

The executive summary and key findings must be disseminated to relevant interested parties, and feedback given to the child (if surviving) and family members/carers. Relevant staff must also be given feedback and debriefed (paras 8.44 and 8.41).

Anonymised copies of the individual management reports, overview report, executive summary, multi-agency action plan, and chronologies must be sent to Ofsted, the relevant Government Office Children and Learners Team, the Strategic Health Authority (SHA) and the DCSF (para 8.44). All SCRs are evaluated by Ofsted (8.46)

LSCBs should monitor and audit actions of agencies against action plan – “at least as much effort should be spent on implementing the recommendations as on conducting the review” (para 8.52)

Once the action plan has been implemented, the LSCB should formally conclude the review process and inform the Government Office (para 8.44).

The NSPCC Safeguarding Information Service has produced a reading list on serious case reviews, which contains links to SCRs published on local authority websites alongside a series of overviews of SCRs.

References

14. HM Government (2010) Chapter 8. In: Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). Nottingham: Department for Children Schools and Families (DCSF).

Please note that this content is of a general nature, and may not represent a comprehensive review of the literature. Search the NSPCC Library catalogue for more publications.