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, 2018a).

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).

The Child Safeguarding Practice Review Panel have published their first Annual Report 2018 to 2019, which analyses 538 rapid reviews received between July 2018 and December 2019 (Child Safeguarding Practice Review Panel, 2020a).

The Panel have also committed to producing thematic reports, sharing the learning from rapid reviews about a particular topic. The first of these is about safeguarding children at risk from criminal exploitation (PDF) (Child Safeguarding Practice Review Panel, 2020b).

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

> Read our CASPAR briefing on the Child Safeguarding Practice Review Panel’s annual report

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

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) has published a report sharing the learning from case management reviews (SBNI, 2019).  

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 significant case review

In Scotland, a significant case review (SCR) should take place if a case raises serious concerns about professional or service involvement. A SCR is carried out when a child has died 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 or accidental death
• the death is by alleged murder, culpable homicide, reckless conduct, or act of violence
• at the time of their death the child was in care (Scottish Government, 2014).

A significant case review can also be carried out when a child has not died but has sustained significant harm or is at risk of significant harm, and the case gives rise to serious concerns about professional or service involvement.

A significant case review should:

• establish the full circumstances of the death/serious harm of the child
• examine and assess the role of all relevant services
• explore any key practice issues and why they might have arisen
• establish whether there are lessons to be learned or good practice to be shared
• identify areas for development
• consider whether there are gaps in the system
• make recommendations needed to improve the quality of services (Scottish Government, 2015).

In Scotland, the key guidance for carrying out significant case reviews is National guidance for child protection committees: conducting a significant case review (Scottish Government, 2015).

Carrying out a significant case review

Initial case review

When the child protection committee (CPC) is notified about a potential significant case, an initial case review is carried out.

The CPC requests all relevant agencies who worked with the child and their family to gather information and submit reports within 14 calendar days.

The CPC considers the information provided in the initial case review and decides whether or not to proceed to a significant case review.

Significant case review

If the CPC decides to proceed to a significant case review, they must next decide whether the significant case review should be led internally or externally.

The CPC may decide to appoint an internal lead reviewer if the circumstances of the case, suggest that any recommendations are likely to have mainly local impact. The team would probably be drawn mainly from within the CPC’s members but CPCs should always consider using external expertise for part of the process in the form of a consultant, professional advisor or critical friend.

The CPC may decide to commission an external lead reviewer if:

• 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
• elected members including members of the Scottish Parliament (MSPs), MPs, councillors and NHS Board members have voiced concerns about the case
• there were concerns about services in the area before the incident took place.
• the child’s family/carers or significant adults have expressed concerns about the actions of the agencies.

The CPC should set up a multi-agency review team to support the lead reviewer. Every effort should be made to involve children/young people/families/carers in the review.

Publishing significant case reviews

Once a review is complete it is up to the child protection committee 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.

Learning from significant case reviews

In order to promote national learning, the findings and recommendations from all significant case reviews should be shared among child protection committees, through the meeting of the Scottish child protection committee chairs forum (SCPCCF). The Forum should consider how to take recommendations and areas of good practice forward at a national level.

SCRs which include a recommendation with national implications should be shared with the relevant organisation and with the Scottish Government.

In 2019, the Care Inspectorate published a review of the learning from significant case reviews that were completed between March 2015 and April 2018 (Care Inspectorate, 2019).

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

Child Safeguarding Practice Review Panel (2020a) Annual Report 2018 to 2019. London: Child Safeguarding Practice Review Panel

Child Safeguarding Practice Review Panel (2020b) It was hard to escape: safeguarding children at risk from criminal exploitation (PDF). 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) (2018a) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (PDF). London: Department for Education.

Department for Education (DfE) (2018b) Working together: transitional guidance: statutory guidance for Local Safeguarding Children Boards, local authorities, safeguarding partners, child death review partners, and the Child Safeguarding Practice Review Panel (PDF). London: Department for Education.

Department for Education (DfE) (2019) Report a serious child safeguarding incident [Accessed 26/02/2019].

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 (PDF).Belfast: Safeguarding Board for Northern Ireland.

Safeguarding Board for Northern Ireland (SBNI) (2019) Learning from case management reviews (PDF). Belfast: SBNI.

Scotland

Care Inspectorate (2019) Learning from significant case reviews (PDF). Dundee: Care Inspectorate.

Scottish Government (2014) National guidance for child protection in Scotland (PDF). Edinburgh: The Scottish Government.

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

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.