Research reports on serious case reviews
December 2011
Reports analysing the details and recommendations from serious case reviews provide a valuable overview of common themes that can make children vulnerable and highlight how professionals and organisations can improve the way they work together to safeguard children.
Yearly and biennial reports analysing serious case reviews in EnglandResearch reports relating to serious case reviewsMajor inquiry reports
Reports analysing serious case reviews in England
2009-2010Ages of concern: learning lessons from serious case reviews: a thematic report of Ofsted's evaluation of serious case reviews from 1 April 2007 to 31 March 2011 (PDF).
Ofsted, 2011.
Analyses serious case reviews evaluated by Ofsted between April 2007 and 31 March 2011. Focuses on cases concerning babies under one year and young people aged over 14. Outlines lessons that can be learnt from the reviews, using case studies to illustrate the points made, and includes practice implications for both practitioners and LSCBs. Includes a more detailed breakdown of serious case reviews evaluated by Ofsted between 1 April 2010 and 31 March 2011.
A study of recommendations arising from serious case reviews 2009-2010 (PDF).
Brandon, Marian, Sidebotham, Peter, Bailey, Sue and Belderson, Pippa
Deparment for Education, 2011.
A critical, thematic analysis of the recommendations from 33 serious case reviews. Focuses on how many recommendations were made, commons themes from the recommendations, how closely the recommendations reflect the themes of the case and critiques the use of SMART (specific, measurable, achievable, relevant and timely) recommendations.
Read the NSPCC briefing on the findings:
A summary of the DfE's "A study of recommendations arising from serious case reviews 2009-2010".
Child and family practitioners' understanding of child development: lessons learnt from a small sample of serious case reviews (PDF).
Brandon, Marian, Sidebotham, Peter, Ellis, Catherine, Bailey, Sue and Belderson, Pippa
Deparment for Education, 2011.
An in-depth study of 6 purposely selected serious case reviews. Considers how the level of knowledge that practitioners, particularly social workers, have on child development might have affected the case and its outcomes.The voice of the child: learning lessons from serious case reviews (PDF).
Ofsted, 2011.
Analysis of 67 serious case reviews evaluated by Ofsted between 1 April and 30 September 2010. Focuses on the importance of listening to the voice of the child.
Read the NSPCC briefing on the findings:
A summary of Ofsted's "The voice of the child: learning lessons from serious case reviews".
Learning lessons from serious case reviews 2009-10 (PDF).
Ofsted, 2010.
Analysis of the evaluations of serious case reviews that Ofsted completed between April 2009 and March 2010. 2007-2009
Building on the learning from serious case reviews: a two-year analysis of child protection database notifications 2007-2009 (PDF).
Brandon, M., Bailey, S. and Belderson, P.
London: Department for Education (DFE), 2010.
Biennial analysis of 268 serious case reviews relating to incidents that occurred between April 2007 and March 2009.
Learning lessons from serious case reviews: year 2 (2008-09) (PDF).
Ofsted
Manchester: Ofsted, 2009.
Analysis of the evaluations of 173 serious case reviews that Ofsted completed between April 2008 and March 2009.
Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 (PDF).
Ofsted
London: Ofsted, 2008.
Analysis of the evaluations of 50 serious case reviews that Ofsted completed between April 2007 and March 2008.
2005-2007
Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005-07 (PDF).
Brandon, M. et al.
London: Department for Children, Schools and Families (DCSF), 2009.
Biennial analysis of 189 serious case reviews arising from incidents that occurred between April 2005 and March 2007. Includes an in-depth analysis of 40 of these reviews.2003 - 2005Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 (PDF).
Brandon, M. et al.
London: Department for Children, Schools and Families (DCSF), 2008.
Biennial analysis of 161 serious case reviews arising from incidents that occurred between April 2003 and March 2005.
2001 - 2003
Improving safeguarding practice: study of serious case reviews 2001-2003 (PDF).
Rose, W. and Barnes, J.
Nottingham: Department for Children, Schools and Families (DCSF), 2008.
Biennial analysis of 40 serious case reviews arising from incidents that occurred between April 2001 and March 2003.
1998 - 2001
Learning from past experience: a review of serious case reviews (PDF).
Sinclair, R. and Bullock, R.
London: Department of Health (DoH), 2002.
Biennial analysis of 40 serious case reviews arising from incidents that occurred between April 1998 and March 2001.
Research reports relating to serious case reviews
An analysis of serious case reviews by the NSPCCNSPCC, 2011.
A brief analysis of the serious case reviews held by the NSPCC Library that concern children aged under one year and were published between 1 January 2008 and 12 September 2011 in England or Wales. Looks at the prevalence of domestic violence, substance misuse or mental health issues in these cases.Serious and fatal child maltreatment: setting serious case review data in context with other data on violent and maltreatment-related deaths in 2009-10 (PDF).
Sidebotham, Peter, Brandon, Marian, Bailey, Sue, Belderson, Pippa and Hawley, Carol
[London]: Department for Education (DfE), 2011.
Compares available data on serious and fatal child maltreatment in England. Estimates drawn from a combination of SCR notifications from 1 April 2009 - 31 March 2010 and comparator data include: the total number of violent and maltreatment-related deaths of children is around 74 per year, with around 50-55 directly caused by violence, abuse or neglect, and a further 20-25 in which maltreatment was considered a contributory factor.
Read the NSPCC briefing summarising the main findings:
A summary of the DfE's "Serious and fatal child maltreatment: setting serious case review data in context with other data on violent and maltreatment-related deaths in 2009-10"
A child-centred system: the government's response to the Munro review of child protection (PDF).
London: Department for Education, 2011.
States the government will consider Professor Munro's recommendation 9 on serious case reviews at a later date.
Read the NSPCC briefing:
A summary of the government's response to the Munro reportThe Munro review of child protection: final report: a child-centred system (PDF).
Munro, Eileen
Norwich: The Stationery Office, 2011.
Considers the role of serious case reviews and learning. Recommendation 9 on using systems methodology when undertaking a serious case review and developing national resources to improve serious case review practice.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.
Child death and serious case review processes in the UK (PDF). CLiCP Briefing 5.
Vincent, Sharon
Edinburgh: University of Edinburgh/NSPCC Centre for UK-wide Learning in Child Protection , 2009
Outlines, compares and contrasts the serious case review processes which have existed since 1989 in England and Wales, 2003 in Northern Ireland and 2007 in Scotland.
Improving practice to protect children in Wales: an examination of the role of serious case reviews (PDF).
[Cardiff]: Care and Social Services Inspectorate Wales (CSSIW), 2009.
Examination of the arrangements for carrying out serious case reviews and of the role of serious case reviews in improving child protection practice in Wales. Reviews procedures and processes, gives brief overview of arrangements in the rest of the United Kingdom and makes recommendations for future practice in Wales.
An evaluation of the case management review process in Northern Ireland: including a scoping exercise of adverse incident reporting and alternative investigative systems.
Lazenbatt, Anne, Devaney, John and Bunting, Lisa
London: NSPCC (and Queens University Belfast), 2009
Identifies the strengths and weaknesses of the case management review (CMR) process and presents recommendations for improvement. Includes a literature review of incident systems and processes used nationally and internationally and their advantages and disadvantages.
Safeguarding children 2008: the third joint chief inspectors' report on arrangements to safeguard children.
London: Ofsted, 2008.
Chapter 4 looks at serious case reviews and reports that there are considerable variations between local safeguarding children boards (LSCBs) in the number of serious case reviews they have carried out. Ofsted’s survey of 118 LSCBs in 2007 showed that around a quarter had not carried out any at all compared with the 5% that had completed five or more.
Major inquiry reports
The protection of children in England: a progress report (PDF).
Laming, Lord
London: The Stationery Office (TSO), 2009.
Report following the death of Peter Connelly. 12 of the 58 recommendations mention serious cases reviews (recommendations 2 and 39 to 49). These cover: ensuring the focus is on the effective learning of lessons to improve individual and multi-agency working; the evaluation of reviews based on learning and recommendations; ensuring panel chairs and overview authors are independent and trained; and the sharing of reviews with appropriate agencies.
The Bichard Inquiry report (PDF).
Bichard, Sir Michael
London, The Stationery Office (TSO), 2004.
Inquiry to examine the child protection procedures in Humberside Police and Cambridge Constabulary following the murders of Holly Wells and Jessica Chapman by Ian Huntley.
The Victoria Climbié inquiry (PDF).
Laming, Lord
Norwich: The Stationery Office (TSO), 2003.
Inquiry into the death of Victoria Climbié who died aged 8 at the hands of her aunt and aunt's boyfriend. Also looks at the failings in the wider child protection system.
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