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Practice guidance on conducting a case review following the death or serious injury of a child

NSPCC reading list

November 2013

A reading list of guidance resources for conducting a case review, learning from the findings and implementing the recommendations.

Learning models for serious case reviews
Practice guidance and learning audits

See also our page on statutory government guidance for England, Northern Ireland, Scotland and Wales.

Learning models for serious case reviews in England

Working together to safeguard children (HM Government, 2013) sets out that:

"LSCBs may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro".

There are a number of different models which are being considered and used by different Local Safeguarding Children Boards (LSCBs). These include:

As yet, nothing has been published that compares the different models.

Practice guidance and learning audits

National panel of independent experts on serious case review: information for LSCBs and Chairs on how the panel will operate (PDF).
[London]: Department for Education (DfE), 2013
Information for Local Safeguarding Children's Boards (LSCBs), outlining the operating guidelines for the national panel of independent experts on serious case reviews. Summarises the scope of the panel, the criteria for reviews, publication of reports, which cases the LSCB Chair should inform the panel about and what the panel needs to be told, how the confidentiality of information will be preserved, how to contact the panel and attendance at panel meetings by LSCB Chairs.

Undertaking serious case reviews using the Social Care Institute for Excellence (SCIE) learning together systems model: lessons from the pilots (PDF).
Munro, E. R. and Lushey, C.
London: Child Wellbeing Research Centre (CWRC), 2013
Evaluates the Social Care Institute for Excellence's (SCIE's) systems model for producing serious case reviews (SCRs). Looks at how the model was used by two Local Safeguarding Boards between January and July 2012. Identifies a high level of commitment to implementing the model in the two pilot areas, and finds that practitioners appreciated its highly collaborative and systemic approach. Highlights a number of issues with the model, including: questions around the ability to generalise learning from individual cases using this model, and its failure to account for the sensitivity of the issues discussed in SCRs.

Training materials and LSCB commissioning material with Knowledge and Skills Framework (PDF).
NSPCC, Sequeli and Action for Children
[Exeter]: Sequeli, 2013
Materials to support the Department for Education programme "Improving the Quality of Children’s Serious Case Reviews through Support and Training" which ran from January 2013 until April 2014 in England. The training materials covers each stage of a case review from guiding principles to choosing a methodology, involving families, sample letters, interviewing, analysing, making recommendations and writing. Sets out the links with official procedures and guidance including: Working together, inquests, Equality Act 2010 and domestic homicide reviews. Presents a Knowledge and Skills Framework designed for the programme. The LSCB commissioning materials cover key principles, a checklist of features a good review report should have and earning from reviews.
Find out more about the Improving the Quality of Children’s Serious Case Reviews through Support and Training programme.

Audit and analysis of initial and significant case reviews (PDF).
Vincent, S. and Petch, A.
Edinburgh: The Scottish Government, 2012
Report analysing 43 initial case reviews (ICRs) and 56 significant case reviews (SCRs) conducted in Scotland between 2007 and 2011. Findings showed: a lack of consistency in how reviews were undertaken. Of the SCRs half of were about child deaths; criminal proceedings had been instigated in half; parental mental health was an issue in 43%; parental substance misuse was an issue in nearly two thirds domestic abuse featured in over half the cases. Presents 10 recommendations to improve the SCR process in Scotland.

What do serious case reviews achieve?
Sidebotham, P.
Archives of Disease in Childhood 97(3): 189-192, March 2012
Questions whether serious case reviews (SCRs) have led to: improvements in safeguarding children; new learning in how to safeguard children; and the implementation of actions to safeguard children. Finds that recommendations from SCRs can be helpful when they are limited, focused and lead to definitive action; but should not be seen as in themselves sufficient evidence that learning has taken place.

Inquiring into non-accidental child deaths: reviewing the review process.
Devaney, J. Lazenbatt, A. and Bunting, L.
British Journal of Social Work, 41(2): 242-260, March 2011
Reports on the findings of a Delphi study that reviewed the process of conducting serious case reviews, based on the views of experienced child protection professionals in Northern Ireland. Concludes that improvements could be made by greater attention to process issues and a stronger emphasis on translating learning into action.

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. Rev. ed.
Handley, M. and Green, R.
London: NSPCC, 2009
An online guide to help local safeguarding children boards (LSCBs) audit the recommendations of case reviews.


HM Government (2013) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). London: Department for Education (DfE).

Contact the NSPCC's information service for more information on case reviews or any child protection topic

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