Child protection 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 that 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 seriously harmed and there is cause for concern about how organisations or professionals worked together to safeguard the child


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

What is seriously harmed and how is it determined

Seriously harmed includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • a potentially life-threatening injury;
  • serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. LSCBs should use available research evidence when considering whether serious harm has occurred. (Department for Education, 2018).

Carrying out a serious case review

Local Safeguarding Children Boards (LSCBs) follow 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.

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 (Department for Education, 2018).

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.

Other ways that LSCBs can learn lessons

Working together to safeguard children sets out that “the review should be proportionate to the circumstances of the case, focus on potential learning, and establish and explain the reasons why the events occurred as they did” (Chapter 4, Section 33, p. 89, Department for Education, 2018).

Some LSCBs are deciding for some cases to carry out "lessons learned reviews" or "critical incident reviews" instead of serious case reviews.

Ofsted have reported a decrease in the proportion of serious incident notifications that resulted in serious case reviews.

The 3rd annual report by the National Panel of Independent Experts highlights that they continue to challenge LSCBs on decisions not to initiate serious case reviews where they feel the cases do meet the statutory criteria.

The government's response to the Wood Report states that the existing system of serious case reviews will be replaced with a system of national and local reviews. There is no further information on how the new system will work.

There is no requirement for LSCBs to publish learning from other types of review, although some LSCBs do publish reports, some of which are available via the National Case Review Repository.

Further information and advice

National case review repository

Working together with the Association of Independent LSCB Chairs to make finding the learning from case reviews published in 2014 and 2013 easy to find.

Find out more

Case reviews published in 2016

A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2016.

Find out more

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