Case review process in UK nations

England

Criteria for carrying out a child safeguarding practice review

In England, child safeguarding practice reviews (previously known as serious case reviews) should be considered for serious child safeguarding cases where:

• abuse or neglect of a child is known or suspected
• and a child has died or been seriously harmed.

This may include cases where a child has caused serious harm to someone else.

Serious harm includes, but is not limited to serious and/or long-term impairment of a child’s mental or physical health or intellectual, emotional, social or behavioural development.

This should include cases where impairment is likely to be long-term, even if this is not immediately certain.

• There are 2 types of reviews:
  Local reviews – where safeguarding partners consider that a case raise issues of importance in relation to their area.
• National reviews – where the Child Safeguarding Practice Review Panel considers that a case raises issues which are complex or of national importance. The Panel may also commission reviews on any incident(s) or theme they think relevant.

In England, the key guidance for safeguarding practice reviews is Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (Department for Education, 2018).

Responsibilities

The responsibility for learning lessons from serious child safeguarding incidents lies with the Child Safeguarding Practice Review Panel at a national level and safeguarding partners at a local level (local authorities, chief officers of police, and clinical commissioning groups).

Local authorities must:

• notify the Child Safeguarding Practice Review Panel and the safeguarding partners in their area (and in other areas if appropriate) within five working days if they know or suspect that a child has been seriously harmed or died as a result of abuse or neglect
• notify the Secretary of State and Ofsted where a looked after child has died, whether or not abuse or neglect is known or suspected.

The Department for Education has published guidance on how local authorities should notify incidents to the Child Safeguarding Practice Review Panel.

At a local level, the safeguarding partners must make arrangements to:

• identify and consider serious child safeguarding cases which raise issues of importance in relation to their area
• commission and oversee child safeguarding practice reviews of those cases, where they consider it to be appropriate.

The safeguarding partners should:

• undertake a rapid review of the case to identify any immediate action to ensure a child's safety, consider the potential for identifying learning and help inform a decision about whether to undertake a child safeguarding practice review.
• send a copy of the rapid review to the Child Safeguarding Practice Review Panel along with their decision about whether to carry out a local child safeguarding practice review and whether they think a national review may be more appropriate.

Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families.

Safeguarding partners are responsible for:

• commissioning and supervising reviewers for local reviews and agreeing the methodology to be used
• ensuring that practitioners, families and surviving children are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

At a national level, the Child Safeguarding Practice Review Panel is responsible for:

• identifying serious child safeguarding cases which raise issues that are complex or of national importance
• overseeing the review of these cases
• setting up a pool of potential reviewers who can undertake national reviews, a list of whom must be publicly available
• agreeing the potential scope and methodology of the review with the local safeguarding partners and engaging with them and others involved in the case.

The Child Safeguarding Practice Review Panel has published practice guidance for those involved in local child safeguarding practice reviews and serious case reviews (Child Safeguarding Practice Review Panel, 2019).

All child safeguarding practice reviews should:

• reflect the child's perspective and the family context
• be proportionate to the circumstances of the case
• focus on potential learning
• establish and explain the reasons why the events occurred as they did.

The Child Safeguarding Practice Review Panel regards a ‘good’ review report as one that includes:

• a brief overview of the key circumstances, background and context of the case
• a summary of why relevant decisions by professionals were taken
• a critique of how agencies worked together and any shortcomings that were identified
• consideration of whether any shortcomings are features of practice in general
• consideration of what would need to be done differently to prevent harm occurring to a child in similar circumstances
• recommendations for what needs to happen to ensure that agencies learn from this case

(Child Safeguarding Practice Review Panel, 2019).

Publishing reports

Reports should be published no later than six months after the date of the decision to carry out a review.

Safeguarding partners must publish local reviews and the Panel must publish national reviews, unless they consider it inappropriate to do so. If the full report is not published there may still be information about improvements for best practice that are appropriate to publish.

Safeguarding partners should set out the justification for any decision not to publish details of a review.

The safeguarding partners should ensure that the way reports are written avoids harming the welfare of any children or vulnerable adults involved in the case. This may include removing intimate personal details of a family’s life.

• Local child safeguarding practice review reports must be publicly available for at least one year.
• The reports of national reviews must be made publicly available for at least three years.

Learning from case reviews

Safeguarding partners must send the reports or learning from them to the Child Safeguarding Practice Review Panel and to the Secretary of State prior to publication. They should also send the report or learning to Ofsted. The Panel should send copies of published reports of national and local child safeguarding practice reviews, or published information relating to improvements that should be made following those reviews, to the What Works Centre for Children's Social Care and other relevant inspectorates, bodies or individuals as they see fit.

The safeguarding partners should highlight findings from reviews with relevant parties locally and should regularly audit progress on the implementation of recommended improvements. Improvement should be sustained through regular monitoring and follow up of actions so that the findings from these reviews make a real impact on improving outcomes for children.

The Department for Education (DfE) has published a series of reports analysing the learning from serious case reviews that were published between 2003-2017. The most recent of these is Complexity and challenge: a triennial analysis of SCRs 2014 to 2017 (Department for Education, 2020).

> Read our briefing on the triennial analysis of serious case reviews

The Child Safeguarding Practice Review Panel have published their Annual report for 2020, which analyses 482 serious incident notifications received between 1 January and 31 December 2020 (Child Safeguarding Practice Review Panel, 2021a).

> Read our summary of the Child Safeguarding Practice Review Panel’s annual report 2020

The Panel has also published an annual review of local child safeguarding practice reviews and rapid reviews (PDF). The review analysed 33 local child safeguarding practice reviews received between December 2019 and December 2020 and 135 rapid reviews completed in January to December 2020 (Child Safeguarding Practice Review Panel, 2021b).

> Read our briefing on the annual review of LCSPRs and rapid reviews

The Panel have also published two thematic reports, sharing the learning from rapid reviews about:

• safeguarding children at risk from criminal exploitation (Child Safeguarding Practice Review Panel, 2020a)
• safeguarding children at risk from sudden unexpected infant death (Child Safeguarding Practice Review Panel, 2020b).

The Panel have committed to producing a third thematic report on non-accidental injuries in children under one (Child Safeguarding Practice Review Panel, 2020c).

> Read our briefing: Safeguarding children at risk from criminal exploitation

> Read our briefing: Sudden unexpected deaths in infancy (SUDI)

Our National case review repository holds copies of published reports, making it easier to access and share learning. 

> Find out more about the National case review repository

Northern Ireland

Criteria for carrying out a case management review

In Northern Ireland, a case management review (CMR) should take place when:

• a child dies or is significantly harmed, and either:
  • 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) and subject to a care protection plan
  • the child, or a sibling of the child was in care.
• there are concerns about the effectiveness of any of the people or agencies represented on the Safeguarding Board in safeguarding and promoting the welfare of children
• there is significant learning to be gained from a review being held which will lead to substantial improvements in safeguarding and promoting the welfare of children in Northern Ireland.

Case management reviews may also take place where effective working has taken place and outstanding positive learning can be gained to improve practice in safeguarding and promoting the welfare of children.

In Northern Ireland, the key guidance for conducting a case management review is Learning from Practice - Case Management Review Process Multi-Agency Guidance (Safeguarding Board for Northern Ireland, 2017).

Carrying out a case management review

When notified of an incident that meets some of the criteria for a CMR, the Safeguarding Board for Northern Ireland (SBNI) will inform the CMR Panel. The panel will ask its members to check their databases and provide any details of service involvement with the child or their family. The SBNI Board will then use the recommendation of the CMR panel to decide whether to commission a CMR.

The CMR panel chair will appoint a CMR team chair and agree the composition of the CRM team who will undertake the review.

The parents and child/young person (if appropriate) will be offered the opportunity to meet with members of review team. In addition to individual agency reports (IARs), insight may be gathered through learning events with practitioners, managers and safeguarding/child protection leads who had been involved in the case.

The case management review should consist of:

• an overview report highlighting the lessons learned and identifying any recommendations for future action to strengthen systems for supporting families and protecting children in the future
• an executive summary which provides a summary of the case and the learning gained
• an action plan for agencies and the SBNI designed to take forward the recommendations and learning from the CMR.

Publishing case management reviews

The CMR executive summaries will ordinarily be published and so should be written in such a way that it is suitable for publication, including protecting the identities of individuals.

The Overview Report contains highly sensitive and confidential information and therefore may only be shared within a framework of confidentiality and data protection.

Learning from case management reviews

Learning from CMRs is shared through the organisations that were involved and with the safeguarding panels chairs and other key stakeholders.

The Safeguarding Board for Northern Ireland (SBNI) publishes annual reports sharing the learning from case management reviews. The report shares learning from CMRs 2019 to 2020 (SBNI, 2020).  

Our National case review repository holds copies of published reports, making it easier to access and share learning.

> Find out more about the National case review repository

Scotland

Criteria for carrying out a learning review

In Scotland, a learning review (previously known as a significant case review) should take place if a child has died, sustained significant harm or been at risk of significant harm, and one or more of the following apply:

• 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
• the death is by alleged murder, culpable homicide, reckless conduct, or act of violence

(Scottish Government, 2021).

A learning review should be carried out if there is learning to be gained which could help improve the protection of other children and young people. This includes areas where practice needs to be improved and examples of good practice (Scottish Government, 2021).

A learning review should focus on understanding:

• what happened
• how some assessments were made
• how people saw things at the time
• what knowledge was drawn on to make sense of the situation
• the resources available
• the emotional impact of the work
• effective practice.

It should also identify learning points and set out how these should be actioned and implemented in the future (Scottish Government, 2021).

In Scotland, the key guidance for carrying out learning reviews is Child protection committees - learning reviews: national guidance (Scottish Government, 2021).

Initiating a learning review

Initial case review

When the child protection committee (CPC) is notified about a case that might meet the criteria for a learning review, they will nominate a person or sub-group to gather more information from the agencies involved with the case. This person or sub-group will assess the information and make a recommendation to the CPC about whether or not to proceed with a learning review.

Carrying out a learning review

The CPC will set up a multi-agency review team to carry out the learning review following a systematic approach. Every learning review should have terms of reference to define the scope of the review. Information about how to carry out the review is provided in the Scottish Government’s national guidance for learning reviews (Scottish Government, 2021).

Learning review report

The learning review report should identify key learning points and explain how and why that learning has emerged through the review process. Proposals for improvement should only be made if there is evidence that they will effectively address the shortcomings identified in the report (Scottish Government, 2021).

The CPC will recommend whether the report should be published, but the final decision is made by the Chief Officers Group (made up of the Chief Officers of each Health and Social Care partnership in Scotland). The Chief Officers Group (COG) should consider:

• confidentiality and data protection
• the views of the family
• how to make sure the publication is suitably anonymised but also clearly reflects the learning emerging from the review

(Scottish Government, 2021).

Learning from reviews

The CPC must make sure an action plan is drawn up, setting out how the strategies for improvement identified in the report will be implemented.

Learning from the review should be shared at a local and national level. At a local level, this aims to:

• make sure the learning is understood by practitioners, managers and organisations
• explore how the learning can be embedded in practice and systems

(Scottish Government, 2021).

At a national level, learning should be shared across CPC areas to inform best practice.

The Learning Review Liaison Group is made up of representatives from the Scottish Government, the Care Inspectorate and CPC Scotland. The group meets to discuss thematic findings from learning reviews that have national implications for policy and practice development.

In 2021 the Care Inspectorate published a triennial review of key themes from initial case reviews and significant case reviews that were submitted between 01 April 2018 and 31 March 2021 (PDF)  (Care Inspectorate, 2021).

> Read our CASPAR briefing that summarises the Care Inspectorate's triennial review

Our National case review repository holds copies of published reports, making it easier to access and share learning.

> Find out more about the National case review repository

Wales

Criteria for carrying out a child practice review

A child practice review (CPR) should take place if child abuse is known or suspected and a child has:

• died
• sustained potentially life threatening injury
• sustained serious and permanent impairment of health or development.

In Wales, the key guidance for conducting child practice reviews is Working together to safeguard people: volume 2: child practice reviews (Welsh Government, 2019).

Carrying out a child practice review

The purpose of a child practice review is to generate professional and organisational learning and promote improvement in future inter-agency child protection practice. The review should focus on current practice, so should normally consider a timeline of up to 12 months preceding the incident.

The review engages directly with children and family members, as they wish and is appropriate. It also involves practitioners who have been working with the child and family, and their managers. A planned and facilitated practitioner-focused learning event is a key element of the review, conducted by a reviewer(s) independent of the case management, to examine current case practice within a limited timeline and using a systems approach.

There are two types of CPR, a concise and extended review:

• a concise review should take place if the child was not on the child protection register or in care at any point in the six months running up to the incident. The review is managed by a review panel and a reviewer is appointed to work with the panel.
• an extended review must take place if the child was on the child protection register and/or was in care at any point during the six months running up to the incident. An extended review is undertaken by two reviewers working closely together, appointed by the review panel.

Publishing child practice reviews

Both concise and extended child practice reviews must be published.

• The final report is approved and published by the safeguarding children board and submitted to the Welsh Government. The process will be completed as soon as possible but usually not more than six months from the date of a referral from the Board to the Review Sub-Group.
• The report must appear on the safeguarding children board website for a minimum of 12 weeks.

Learning from child practice reviews

Both concise and extended reviews must include an action plan.

• The action plan is finalised within four weeks of the final report, approved by the safeguarding children board, and submitted to the Welsh Government.
• Action plans should lead to improvements in child protection practice.
• The implementation of the action plan must be regularly reviewed and progress should be reported to the safeguarding children board.
• The safeguarding children board must ensure action plans are being carefully audited.
• The safeguarding children board must submit a report to the safeguarding team of the Welsh Government on the differences the actions have made to practice.

Our National case review repository holds copies of published reports, making it easier to access and share learning.

> Find out more about the National case review repository

References and resources

England

Child Safeguarding Practice Review Panel (2021a) Annual report 2020. [Accessed 07/09/2021].

Child Safeguarding Practice Review Panel (2021b) Annual review of local child safeguarding practice reviews and rapid reviews (PDF). [Accessed 07/09/2021].

Child Safeguarding Practice Review Panel (2020a) Safeguarding children at risk from criminal exploitation. London: Child Safeguarding Practice Review Panel.

Child Safeguarding Practice Review Panel (2020b) Safeguarding children at risk from sudden unexpected infant death. [Accessed 07/09/2021].

Child Safeguarding Practice Review Panel (2020c) Child Safeguarding Practice Review Panel: third national review. [Accessed 07/09/2021].

Child Safeguarding Practice Review Panel (2019) Child safeguarding practice review panel: practice guidance. London: Child Safeguarding Practice Review Panel.

Department for Education (DfE) (2020) Complexity and challenge: a triennial analysis of serious case reviews 2014 to 2017. London: Department for Education.

Department for Education (DfE) (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. [Accessed 07/09/2021].

Department for Education (DfE) (2019) Report a serious child safeguarding incident. [Accessed 07/09/2021].

Northern Ireland

Department of Health, Social Services and Public Safety (2014) Guidance to Safeguarding Board for Northern Ireland (SBNI) (PDF). Belfast: Department of Health, Social Services and Public Safety

Safeguarding Board for Northern Ireland (SBNI) (2017) 'Learning from practice' case management review process multi-agency guidance. Belfast: Safeguarding Board for Northern Ireland.

Safeguarding Board for Northern Ireland (SBNI) (2020) Learning from CMRs 2019 - 2020. [Accessed 07/09/2021].

Scotland

Care Inspectorate (2021) Triennial review of initial case reviews and significant case reviews (2018-2021): impact on practice (PDF). Dundee: Care Inspectorate.

Scottish Government (2021) Child protection committees - learning reviews: national guidance. [Accessed 07/09/2021].

Wales

Welsh Government (2019) Working together to safeguard people: volume 2: child practice reviews (PDF). Cardiff: Welsh Government.

Further reading

Learning from case reviews
Our series of thematic briefings highlight the learning from case reviews on different topics including: child sexual exploitation; infants; parents with a mental health problem; learning for specific sectors.

For further reading about case reviews, search the NSPCC Library catalogue using the keyword "official enquiries".

If you need more specific information, please contact our Information Service.

Related resources 

Child deaths due to abuse or neglect: statistics briefing
We have produced a briefing which brings together the available data and statistics about child deaths due to abuse or neglect.

Inter-professional communication and decision making
The NSPCC, in partnership with the Social Care Institute for Excellence (SCIE), analysed 38 serious case reviews and identified practice issues relating to how professionals in different agencies communicate and make decisions. We’ve created 14 briefings to provide a more detailed understanding of practice issues highlighted by the SCR reports. 

Serious case review quality markers
The NSPCC, in partnership with SCIE, created a set of quality markers to support commissioners and reviewers to commission and conduct high quality reviews.