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).
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).
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:
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