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Serious Case Reviews

Child Safeguarding Practice Reviews

A Child Safeguarding Practice Review is held when a child has died and abuse or neglect is known or suspected to be a factor in the child's death.

Reviews may also be held when a child has been seriously injured through abuse or neglect and where those who know about the child's circumstances believe that lessons could be learned to avoid a similar situation arising in the future.  The Review carefully considers the circumstance, surrounding the death/injury which took place prior to the incident.

This means that most child deaths do not lead to Child Safeguarding Practice Reviews.  However, it is important to remember that the death of a child is always tragic and we must take whatever steps we can to avoid a similar incident happening in the future. 

The Government provides advice and guidance to all agencies that work with children about how to conduct a Child Safeguarding Practice Review.  These are contained in "Working Together to Safeguard Children 2018" which defines the purpose of a Serious Case Review as follows:

The purpose of a child safeguarding practice review is to explore how practice can be improved through changes to the system itself. Reviews should seek to understand both why mistakes were made and to comprehend whether mistakes made on one case frequently happen elsewhere and to understand why.

Holding organisations and their leaders to account for the quality of services, and individuals to account for not meeting professional standards are essential pre-requisites for public confidence in the national safeguarding system. Regulatory bodies for the professions hold this key role. Reviews are not designed for this purpose and will not be used in this way. Nevertheless, where reviews identify any actual or potential errors or violations, they should ensure that proper lines of accountability are followed to ensure that those responsible are held to account.

Practice Learning Review

In some instances it will be apparent from the outset that the criteria for initiating a SCR have not been met. The Board recognises that reviews of such cases may provide opportunity to identify learning to be disseminated to staff in a timely manner. In order to enable all agencies to benefit from such, HSCB has produced the

Multi-Agency Practice Learning Review process.

The Multi-Agency Practice Learning Review process provides a timely approach which enables reflection upon a case by practitioners, and where appropriate, the child(ren) and family, and adults. The process aims to identify and disseminate learning in a timely manner.

The local guidance for carrying out Child Safeguarding Practice Reviews and other reviews is currently being updated

Learning Lessons from Child Safeguarding Practice Reviews and other reviews

All reviews and their recommendations and associated learnings will be published on these pages

Abusive Head Trauma - 7 minute learning

Childhood Obesity Awareness -  7 minute learning Fractures in Infants - 7 minute learning

Childhood Neglect - 7 minute learning

Children with Disabilities - 7 minute learning

NSPCC Case Reviews pages

Click on the links below for NSPCC Case Reviews pages including the national Case Review Repository containing a searchable resource over 1,000 reports from across the UK:

NSPCC Case Reviews pages including Case Review Repository

NSPCC Learning from Serious case reviews