Practice guidance on conducting a case review following the death or serious injury of a child
August 2011
A reading list of guidance resources for conducting a case review, learning from the findings and implementing the recommendations.
Statutory government guidance for England, Northern Ireland, Scotland and WalesSystems model approach to conducting serious case reviews and the Munro reviewPractice guidance for conducting serious case reviewsLearning from serious case reviews
Statutory government guidance for England, Northern Ireland, Scotland and Wales
England, Northern Ireland, Scotland and Wales have separate guidance on the responsibilities of the local inter-agency group and guidance on when and how to carry out a case review following the death or serious injury of a child.
See our page listing the
Statutory government guidance for England, Northern Ireland, Scotland and Wales.
Systems model approach to conducting case reviews and the Munro review
Systems model
The Social Care Institute for Excellence (SCIE) applied a multi-agency systems model adapted from accident investigation methods to the process of conducting a case review. Their
Learning together model aims to identify patterns of factors that contribute to good or problematic practice.
Munro review of child protection (in England)In June 2010 the Secretary of State for Education asked Professor Eileen Munro to conduct a review of the child protection system in England. In May 2011 her findings were published.
Recommendation 9 of The Munro review of child protection states:
"The Government should require LSCBs to use systems methodology when undertaking Serious Case Reviews (SCRs)."
From p.12 of: Munro, Eileen (2011) The Munro review of child protection: final report: a child-centred system (PDF) . [Norwich]: The Stationery Office (TSO).
In July 2011 the Department for Education published the government's response to Professor Munro’s review. The government agreed that systems review methodology should be used by LSCBs in England. Other sections of recommendation 9 are under consideration.
Read the NSPCC briefing:
A summary of the government's response to the Munro report.
Systems model resourcesSCIE have produced an overview, a report, a guide and a film explaining the model and showing agencies how to review the way they learn from case reviews and how to use this learning to genuinely improve practice. SCIE have also published the findings from an evaluation of three pilots of the model and a comparison of the systems model with usual practice.
- At a glance 01: Learning together to safeguard children: a ‘systems’ model for case reviews
Fish, Sheila
London: Social Care Institute for Excellence (SCIE), 2009
An introduction to SCIE's systems approach to conducting case reviews.
- SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews.
Fish, Sheila, and Munro, Eileen, and Bairstow, Sue
London: Social Care Institute for Excellence (SCIE), 2008.
Looks at developing a typology of patterns for child welfare by producing a narrative of multi-agency perspectives and a table of practice episodes and their contributory factors. Suggests data collection should be an ongoing, participative, interpretive process, incorporating the case review model into day-to-day work.
- SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews.
Fish, Sheila, and Munro, Eileen, and Bairstow, Sue
London: Social Care Institute for Excellence (SCIE), 2008.
Covers case reviews and case reviews of routine practice, stressing the importance of organisational learning from ordinary work, not just tragedies. Includes practical guidelines from identifying a case for review, selecting the review team, preparing participants to data collection and analysis. Suggests moving beyond case chronology to consider the differing views that different workers had at the time.
- Safeguarding children: a new approach to case reviews.
Social Care TV
London: Social Care Institute for Excellence (SCIE), 2009.
Film (22 mins.) introducing the systems model approach to conducting case reviews.
- At a glance 34: Piloting the SCIE ‘systems’ model for case reviews: Learning from the North West of England.
Fish, Sheila, and Munro, Eileen, and Bairstow, Sue
London: Social Care Institute for Excellence (SCIE), 2010.
Describes the evaluation of three pilots that used the learning together systems model approach to conducting case reviews. Briefly sets out the findings, what supported effective learning and the challenges in implementing the approach. Full report is also available: Piloting the SCIE ‘systems’ model for case reviews: learning from the North West (PDF) and Supplement A: illustrative final report (PDF).
- Serious case reviews: piloting the SCIE model.
Social Care TV
London: Social Care Institute for Excellence (SCIE), 2011.
Film (24 mins.) describes the development and two pilots of the systems model approach to conducting case reviews.
- SCIE Learning Together (PDF).
Fish, Sheila
London: Social Care Institute for Excellence (SCIE), 2011
Sets out the key features of SCIE Learning Together or systems approach to carrying out a case review. Compares this method with the usual process and practice.
For more information and for findings of the pilots SCIE has been running,
visit SCIE's Learning Together pages.
Practice guidance for conducting case reviews
A selection of guidance produced by LSCBs:
London serious case reviews toolkit (PDF).
London Safeguarding Children Board, 2010
Supplementary guidance for undertaking a serious case review (SCR). It focus to support the carrying out of a SCR effectively, through supporting consistency in approach, providing additional guidance on undertaking the process and sharing learning and emerging good practice tools and exemplars.
Learning from case reviews
Learning from serious case reviews: report of a research study on the methods of learning lessons nationally from serious case reviews (PDF).
Sidebotham, P. et al
London: Department for Education, 2010.
Contains recommendations on how to improve approaches to learning from serious case reviews.
Safeguarding through audit: a guide to auditing case review recommendations.
Handley, Mary, and Green, Richard
Rev. ed. London: NSPCC, 2009
An online guide to help local safeguarding children boards (LSCBs) audit the recommendations of case reviews.
Copyright © 2011 NSPCC - All rights reserved. National Society for the Prevention of Cruelty to Children, Weston House, 42
Curtain Road, London EC2A 3NH. Incorporated by Royal Charter. Registered charity number 216401. NSPCC, charity registered in Scotland, charity number SC037717.