Child protection in Scotland Significant case reviews

A significant case review 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 England they are called serious case reviews; in Northern Ireland, case management reviews and in Wales, child practice reviews.

A significant case review should take place if a case raises serious concerns about professional or service involvement and EITHER:

a child has died and

  • abuse or neglect is known, or suspected, to have been involved
  • the child, or a sibling, was at any point in their life on the child protection register (CPR)
  • the death is by suicide or accidental death
  • the death is by alleged murder, culpable homicide, reckless conduct, or act of violence
  • the child was in care

OR

  • a child has, or could have been, significantly harmed due to abuse or neglect.

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 professional judgement using the gathered evidence.

 Legal definitions for the 4 nations:

Carrying out a significant case review

The local child protection committee (CPC) follows national guidance for conducting significant case reviews.

When the CPC is made aware of a case that could be “significant”, an Initial Case Review ICR) takes place. The committee asks people and services who worked with the child or their family to supply information about the case.  This information is used to decide whether or not to proceed to a SCR.

If it is the committee will next decide whether the review should be internal or external:

If it looks like the recommendations from a case are likely to have a mainly local impact, an internal review will take place.  This means that the investigating and writing of the review can be done by members of the Child Protection Committee (CPC). 

An external review may take place if either:

  • learning from a case will be useful for the whole of Scotland
  • recommendations will be useful to lots of different agencies
  • the case is high profile or likely to attract media attention
  • there were concerns about services in the area before the incident took place.

External significant case reviews are written and investigated by an external team of experts, commissioned by the local CPC.

The local CPC should identify the right reviewer and review team for the job. This should include someone with a broad knowledge of children's services and representatives from the services involved in the case.

The review team will then investigate the case. This should involve speaking to the family and the professionals who worked with them. The team will identify lessons that could be learnt from the case and will put forward recommendations.

Publishing significant case reviews

Once a review is complete it is up to the CPC (with chief officers’ approval) to decide whether to publish the full report or just the executive summary.

Before publication the report will be anonymised to protect the identities of people involved in the case.

Published case reviews in the UK

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.
View the list

Case reviews published in 2015

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 2015.
View the list

Case reviews published in 2014

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 2014.
View the list

National case review repository

In collaboration with the Association of Independent LSCB Chairs, we store published case reviews from 2013 - 2015 in our library catalogue.

Search case reviews

Case reviews published in 2013

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 2013.
View the list

How lessons are learnt

Once a review is completed, the CPC identifies how its analysis and recommendations can best inform learning and practice.

This may involve:

  • CPCs reviewing their own guidance and procedures
  • passing on recommendations for consideration by relevant bodies or the Scottish Government.

Since April 2012 all SCRs are submitted to the Care Inspectorate. The Care Inspectorate will report regularly on key themes to help all CPCs improve local practice. 

Scottish Government (2015) National guidance for child protection committees: conducting a significant case review (PDF). Edinburgh: Scottish Government.

Case reviews

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