Child protection system in England Serious case reviews

A serious case review (SCR) takes place after a child dies or is seriously injured and abuse or neglect is thought to be involved. It looks at lessons than can help prevent similar incidents from happening in the future.

Other parts of the UK have their own systems in place to learn from cases. In Wales they are called child practice reviews; in Northern Ireland, case management reviews and in Scotland, significant case reviews.

A SCR should take place if abuse or neglect is known, or suspected, to have been involved and

  • a child has died
  • or a child has been significantly harmed and there are serious concerns about how organisations or professionals worked together to safeguard the child

or

  • the child dies in custody
  • or a child died by suspected suicide.

What is significant harm and how is it determined

"Harm" is the "ill treatment or the impairment of the health or development of the child".

It is determined "significant" by "comparing a child's health and development with what might be reasonably expected of a similar child".

Although there is no absolute criteria for determining whether or not harm is significant, local authorities such as social services, police, education and health agencies work with family members to assess the child, and a decision is made based on their judgement.

Legal definitions for the 4 nations:

Process for carrying out a serious case review

The Local Safeguarding Children Boards (LSCB) follows statutory guidance for conducting a serious case review.

The decisions to conduct an SCR should be made within one month of the notification of the incident. The LSCB must notify the national panel of independent experts and Ofsted of this decision.

The LSCB should appoint one or more reviewers to lead the SCR. The lead reviewed must be independent of the LSCB and any organisations who are involved with the case. The LSCB should submit the names of these reviewers to the national panel of independent experts.

For the review process, the LSCB should make sure there is appropriate representation of the different professionals and organisations who were involved with the child and the family. The LSCB may decide to ask them to give written information about their involvement with the child.

The LSCB should aim to complete an SCR within 6 months.

Publishing the findings

The final SCR report, and the LSCBs response to the findings, must be published on the LSCB website for a minimum of 12 months and should be available on request. This is important for sharing lessons learnt and good practice in writing and publishing SCRs.

SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.

The final 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 both professionals and the public and
  • be suitable for publication without needing to be amended or redacted.

The LSCB should send a copy of the final SCR to the national panel of independent experts at least one week before publication.

National case review repository

Search our collection of case reviews via the NSPCC library online.

Search case reviews

How lessons are learnt

Working together to safeguard children sets out the need for professionals and organisations protecting children to reflect on the quality of their services and learn from their own practice and that of others.

LSCBs are expected to maintain a local learning and improvement framework. The framework supports regular case reviews (including SCRs) to identify useful insights into the way that organisations are working together to safeguard and protect the welfare of children.

Reviews aim to:

  • look at what happened in cases and why
  • identify action to drive improvements in the prevention of death, serious injury or harm to children.