Serious Case Reviews
Serious Case Reviews
Professionals and organisations protecting children need to
reflect on the quality of their services and learn from their own
practice and that of others. Good practice should be shared so that
there is a growing understanding of what works well. Conversely,
when things go wrong there needs to be a rigorous, objective
analysis of what happened and why, so that important lessons can be
learnt and services improved to reduce the risk of future harm to
These processes should be transparent, with findings of reviews
shared publicly. The findings are not only important for the
professionals involved locally in cases. Everyone across the
country has an interest in understanding both what works well and
also why things can go wrong.
The different types of review include:
- Serious Case Review for every case where abuse or neglect is
known or suspected and either:
- a child or young person dies; or
- a child or young person is seriously harmed and there are
concerns about how organisations or professionals worked together
to safeguard the child or young person;
- child death review, a review of all child deaths up to the age
- review of a child protection incident which falls below the
threshold for an SCR; and
- review or audit of practice in one or more agencies
What is a Serious Case Review?
In a very small proportion of cases when a child or young person
is seriously injured or dies and abuse or neglect is known or
suspected to be a factor an independent panel of experts are
commissioned to carry out a Serious Case Review. The purpose of
Serious Case Reviews is to:
- Establish what lessons are to be learned from the case about
the way in which local professionals and organisations work
individually and together to safeguard and promote the welfare of
- Identify clearly what those lessons are both within and between
agencies, how and within what timescales they will be acted on, and
what is expected to change as a result; and
- Improve intra- and inter-agency working and better safeguard
and promote the welfare of children.
Serious Case Reviews are not inquiries into how a child died or
was seriously harmed, or into who is culpable. These are matters
for coroners and criminal courts, respectively, to determine as
appropriate. Serious Case Reviews focus on improving practices that
safeguard and promote the welfare of children.
Submission of this form should only be by your agency's BBSCB
Liaison Officer (SLO), where they consider there is an inter or
intra-agency learning opportunity; or where there is likely to be
media interest in a case. BBSCB will use this form to consider
whether there is a need for:
- Agency Individual Management Reviews
- Small Scale Audit e.g. Significant Incident Learning
- Serious Case Review
- Other action to promote learning and good practice.
Click here for the Significant Incident Notification Form to
Working Together 2015
Together to Safeguard Children - A guide to inter-agency working to
safeguard and promote the welfare of children 2015)
power point presentation is for agencies to discuss within
their teams and outlines the learning from 3 recent national
serious case reviews in respect of
(Presenters will need to print off the pages as 'notes pages' so
that they have access to the trainer notes which assist in the
delivery of the slides).
To access each report please
click on the name of the child to open the report.
The NSPCC's Knowledge and Information Service
has published a briefing for GPs and primary healthcare teams
summarising learning for improved practice taken from recently
published serious case reviews.
More information can be found on the
The Serious Case Review (SCR) Panel has published a report
detailing its work in the second year of operation. It makes a
number of recommendations including: LSCB chairs should appoint SCR
reviewers with strong analytical skills who have the ability to
produce a clear, succinct account of what happened and why and what
needs to change to prevent it happening again.
Department for Education 10 November 2015
Second report of the national panel of independent experts on
serious case reviews (PDF)
Serious Case Reviews around Child Sexual Exploitation
Operation Brooke Serious Case Review - March 2016
Derby - to
see the Executive summary of this case please click here.
For the document click here
Inquiry - click here to see the document
click here to see full document
Serious Case Review - Baby Sama - Published 4th April 2017
Bedford Borough Local Safeguarding Children Board has carried
out a Serious Case Review following the tragic death of a
In October 2015, the mother and father of baby Sama (not their
real name) were involved in an altercation outside Sama’s home
address. Her father was the driver of a vehicle, and her mother was
standing outside of the vehicle holding Sama in a car seat.
Somehow, as father was driving away, Sama fell from her car seat
and was fatally injured.
An investigation was being carried out into the death of baby
Sama which concluded it was a tragic accident and there was no
intention to wilfully or maliciously cause injury to Sama
The purpose of the Serious Case Review is to look at the work of
organisations working alongside the family involved in this tragic
death and identify any improvements that can be made to the service
they provide. It is about looking to see what lessons can be learnt
to support children and young people in the Borough.
This case review considered the way agencies worked together to
support and safeguard baby Sama up to the point of her death.
for the baby Sama report. There are key areas where the Board
will be looking at improvement and holding partners to
account. Click here
for the Practitioner briefing for Baby Sama case.
Serious Case Review - Patrick - and Thematic Review - Published
on the 23rd May 2016
Please find attached a Serious Case Review in respect of
Patrick whose death was a shock to all the professionals involved
in his life.
Whilst the review did not conclude that his death could have
been prevented or predicted, there are factors identified in this
case which mirror findings in other Serious Case Reviews of
disabled children and young people and Patrick’s review suggests
that disabled and young people in Bedford Borough may not be
afforded the level of scrutiny and investigation that their
conditions require when indicators of abuse and neglect are
here for the Patrick report.. There are three key areas where
the Board will be looking at improvement and holding partners to
account. Click here
for the Practitioner briefing for this case.
Alongside the publication of Patricks SCR is an
independently-led Thematic Serious Case Review which underpins a
need for staff working with disabled and young people to be ever
vigilant and open to the concept that they may be suffering harm
either through omission or through neglect, and found that there
was evidence of both overlaps and gaps, as well as parental and/or
practitioner confusion, in terms of agencies’ roles and
responsibilities. Click on this
link for the Thematic Review. Also attached is a Practitioner
Briefing for this Thematic SCR for dissemination to all staff. In
summary, the Bedford Borough Safeguarding Children Board has learnt
a lot about the quality of current practice and the support offered
to disabled children, young people and their families. There are
three key areas where the Board will be looking at improvement and
holding partners to account.
Click here for the Practitioner briefing.
That all agencies providing services to disabled adults,
children and their families must work more closely together.
That frontline practitioners recognise the signs and symptoms of
neglect including the neglect of older disabled young people and
understand their daily lived experiences
Safeguarding and child protection is promoted to practitioners
as being 'everyone's responsibility' and that this is particular
the case where they are working with children or with adults in the
The Board’s Serious Incident Review Group will monitor the
improvement plans for both these SCRs and details of a Learning
event and further resources will follow.
Serious Case Review - Published the 11th May 2016
Hertfordshire Local Safeguarding Children’s Board published the
Serious Case Review (SCR) into 4 year old girl known as Sophie, who
died at the hands of her father in March 2014. Prior to her moving
in with her father in December 2013 she was a looked after
child in Bedford until court proceedings determined that she should
live with her father. He was convicted of her murder in May 2015,
sentenced to life imprisonment and ordered to remain in prison for
21 years before being considered for release.
View the Hertfordshire Safeguarding
Children Board Serious Case Review report "Sophie."
Other Local Serious Case Reviews