Triennial analysis of serious case reviews from 2011 to 2014

Summary of main findings and recommendations from an analysis of SCRs

The Department for Education has published Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 (PDF), an analysis of serious case reviews (SCRs) relating to incidents from April 2011 to March 2014.

This is the 5th in a series of studies of SCRs in England, dating back to 2003-2005, which have all been carried out by the same team of researchers at the Universities of East Anglia and Warwick.

As well as identifying themes and trends from the 293 SCRs under consideration, this report looks at the context of learning from SCRs over the last 10 years.


The child protection system

  • Once a child is known to be in need of protection the system is, on the whole, working well. However there are pressure points at the boundaries into and out of the child protection system.
  • The number of SCRs carried out since 2012 has increased but this has been in the context of a steady increase in child protection activity.
  • It is important to note that for many children harm was suffered in spite of good work being done to protect them.

Pathways to harm

  • Practitioners should explore all potential cumulative risks to the child. These include:
    • the characteristics and backgrounds of family members
    • awareness of how children are vulnerable at different ages
    • environmental circumstances.
  • The impact of domestic abuse on all family members is highlighted, particularly the effects of coercive control. Some behaviours which may appear inconsistent and potentially harmful can be understood very differently when appraised in the light of coercive control and professionals need to be aware of this.

Pathways to prevention and protection

  • Professionals should focus on children's needs and identifying vulnerable families. Space to hear the voice of the child as well as the immediate and wider family must be created.
  • A culture of communication is important. Clear systems and guidance are needed so that information is verified, shared promptly with all relevant parties and used to guide decision making.
  • Assessments should be planned, comprehensive, timely and involve all professionals working with the family. They should be ongoing and inform decision making.
  • Professionals from a complex mix of agencies can work with a family, often in relative isolation. Pathways between services should be planned to maintain support for vulnerable families.
  • Professionals should have a wide view of their own responsibility and not make assumptions about the actions or views of others, including parents.
  • All leaders and managers need to think creatively to support front-line workers in the context of limited resources.
  • The ongoing nature of vulnerability needs to be recognised. There is a need to shift from an episodic service to a culture of long term continuous support.
  • The cases highlighted by SCRs are complex. To respond to this professionals at all levels should take an authoritative approach:
    • exercising their own judgement
    • taking responsibility for their own role
    • respecting the roles of others
    • building a relationship of trust with families and children
    • challenging situations from a supportive base.

Quality of serious case reviews

  • The SCRs analysed included 9 different types of review methodology which resulted in several different types of report.
  • There has been a trend towards shorter reviews with fewer recommendations.
  • Many SCRs take a systems approach focussing on the identification of learning opportunities. This means findings can be presented in a more accessible way and analysed more deeply by practitioners. However sometimes specific recommendations may still be necessary.
  • Good quality SCRs should include:
    • Lessons learnt which are clearly linked to findings.
    • Questions for the Local Safeguarding Children Board (LSCB) which aim to promote deeper reflection.
    • Specific recommendations where there is a clear need for change.
    • A strategy for dissemination which will enable learning to reach relevant practitioners and managers.
    • Requirement for the LSCB for develop a response and action plan based on the learning from the SCR.

Recommendations from analysis

The report recommends an approach that moves away from analysing whether serious harm could have been prevented, to recognising that there is always room for improvement in our systems. This involves understanding that children are harmed within a complex context of vulnerability but also knowing that there are many opportunities to protect them. An authoritative approach is recommended which combines authority, empathy and humility and allows professionals working with families to support and challenge.

Please cite as: Sidebotham, P., Brandon, M., Bailey, S., Belderson, P., Dodsworth, J., Garstang, J., Harrison, E., Retzer, A. and Sorensen, P. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: final report. [London]: Department for Education.

Find out more about serious case reviews

National case review repository

We have been working with the Association of Independent LSCB Chairs to create the national case review repository to make it easier to access and share learning at a local, regional and national level.

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Learning from case reviews

Our series of thematic briefings highlight the learning from case reviews. Each briefing focuses on a different topic and pulls together key risk factors and practice recommendations.
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Serious case reviews

Details what serious case reviews are, the case review procedure in England and how lessons are learnt. 
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