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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.

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 children.

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
  • a child or young person dies
  • 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 of 18
  • review of a child protection incident which falls below the threshold for an SCR
  • 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 children
  • 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
  • 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.

Significant incident

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 eg Significant Incident Learning Process
  • Serious Case Review
  • Other action to promote learning and good practice.

Significant Incident Notification Form to BBSCB (Word)

Working Together 2015

Working Together to Safeguard Children is a guide to inter-agency working to safeguard and promote the welfare of children.

National SCRs

The attached Powerpoint presentation is for agencies to discuss within their teams and outlines the learning from three recent national serious case reviews in respect of:

  • Daniel Pelka
  • Keanu Williams
  • Hamzah Khan

(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).

All Serious Case Reviews can be found on the NSPCC website

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 NSPCC website.

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

Serious Case Reviews around child sexual exploitation

Operation Brooke Serious Case Review - March 2016

Serious Case Reviews around child and adolescent mental health services

The NSPCC has published a summary of risk factors and learning for improved practice for child and adolescent mental health services (CAMHS) based on findings from case reviews published since 2015.

The summary highlights issues for learning including: listening to young people; understanding how young people use social media and awareness of the influence of websites which promote destructive thinking and behaviour; working with young people who don’t want to engage; and intervening early.

Source: NSPCC Date: 21 July 2017 

Local SCRs

Serious Case Review – Baby Adam - Published 10 July 2019

Bedford Borough Safeguarding Children Board has carried out a Serious Case Review following Adam being removed from his mother’s care and placed with his father, but then he sustained a serious injury which led to them being placed in care. This Serious Case Review considered whether there is a pattern of over-emphasis on the rights to a family life that may be leaving children and young people at risk.  

The purpose of the Serious Case Review is to look at the work of organisations working alongside the family involved 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 Adam. View the Adam report.

There are key areas where the Board will be looking at improvement and holding partners to account. View the Practitioner briefing for Adam case. 

Serious Case Review - Rosie - Published 4 December 2018

Bedford Borough Safeguarding Children Board has carried out a Serious Case Review following Rosie who was three and a half years of age and was found to be suffering from life-limiting and life-changing neglect within her family home. As a result, Rosie required urgent hospital treatment and will have ongoing health and care needs into the future.

The purpose of the Serious Case Review is to look at the work of organisations working alongside the family involved 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 Rosie View the Rosie report.

There are key areas where the Board will be looking at improvement and holding partners to account. View the Practitioner briefing for Rosie case.

Serious Case Review - Telford and Wrekin - June 2018

On 1st June 2018 the Telford and Wrekin Safeguarding Children Board (TWSCB) published the Serious Case Review (SCR) Report in relation a family of five children, known as Family Q, who were subjected to significant neglect within the Borough and within Bedford Borough.

The TWSCB commissioned this SCR to be conducted under Working Together 2015, using an independent reviewer that did not have relationships to any of the organisations involved in this case. In accordance with legislation an Overview Report has been completed and published (PDF).

Serious Case Review - Faith - Published 12 December 2017

Bedford Borough Safeguarding Children Board has carried out a Serious Case Review.

Faith was removed from the care of her parents due to neglect aged 15 months, and placed in foster care. 6 months later Faith was admitted to hospital because she could not stand on one of her feet. She was found to have eight separate limb fractures of which seven were assessed to be non-accidental and to be no older than two months. The injuries had therefore occurred whilst Faith was in care and her case was the subject of care proceedings.

The circumstances of Faith’s injuries have not been established which posed particular challenges for this SCR, whose task was not to attribute blame. The criminal investigation had ended before this SCR commenced, without any charges being brought either for Faith’s neglect or for her subsequent injuries.

This SCR has sought to understand what can be learned from Faith’s experiences whilst a Looked After Child (LAC) in order to try and prevent other children being injured in similar circumstances and to improve the way in which professionals work in the future.

There are key areas where the Board will be looking at improvement and holding partners to account.

Serious Case Review - Baby Sama - Published 4 April 2017

Bedford Borough Local Safeguarding Children Board has carried out a Serious Case Review following the tragic death of a child.

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.

There are key areas where the Board will be looking at improvement and holding partners to account. 

Serious Case Review - Patrick - and Thematic Review - Published 23 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 present.

There are three key areas where the Board will be looking at improvement and holding partners to account.

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. 

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.

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 family.

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 11 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" (PDF)

Other local Serious Case Reviews

Child A1301 Full Report (PDF)

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