Skip to main content

Learning from cases and audits

For more information on the Learning  and Improvement Framework please access chapter 4 of Working Together 2015.

In pursuit of the overall effectiveness of the Bedford Borough Safeguarding Children Board in improving outcomes for children and young people, the Board has a key role in identifying what needs to change to make a difference to the lives of children and young people.

The Board engages in numerous activities to establish what is working well and what needs improvement, and this framework will provide an opportunity to make the required links between the identification of what needs to improve and the various mechanisms available to the Board to achieve those improvements.

Download the BBSCB Learning and Improvement Framework

Local learning

Learning from Pan Bedfordshire Multi Agency Audits 2018 - 2019

Working Together to Safeguard Children (2018) requires Local Safeguarding Children Boards to evaluate multi-agency working through joint audits of case files.

The following audits have been a key area of focus for all 3 of the Bedfordshire LSCB’s and therefore it was agreed that Pan Bedfordshire Multi-Agency audits should be carried out to evaluate current practice within these areas.

The following audit summaries capture the issues identified, good practice and learning which will support improvements in practice aimed at strengthening safeguarding of children and young people.

The audits included accuracy of case details and how the voice and lived experiences of children and young people are captured and addressed.

Pan Bedfordshire Emotional Wellbeing and Mental Health Audit (PDF)

Pan Bedfordshire Missing Children and Young people Audit (PDF)

Pan Bedfordshire GCP2 Audit (PDF)

Pan Bedfordshire Child Sexual Abuse in the Family Environment (PDF)

Learning review - Rosza and Malika

This case did not meet the threshold for a Serious Case Review however, Bedford Borough Safeguarding Children Board (BBSCB) agreed that there was sufficient learning to be gained about how agencies worked together to merit a review of practice.

The case showed how difficult it is for agencies to retain a child-centred focus when assessing the impact of parental physical and mental illness, particularly in relation to non-stereotypical perceptions of what constitutes neglect and when a parent has the ‘louder’ presenting issues.

The full report will not be published following consultation with the children in this case however please find attached a learning briefing to be disseminated to staff. Download for the Learning briefing (PDF). 

Case File Audit in respect of the JS Case - January 2015

This report was commissioned by Bedford Borough Safeguarding Children Board, (BBSCB), following concerns raised by the Family and Children’s Early-Help Service, (FACES) about a child, JS, that they had been working with.

The BBSCB Learning and Improvement Standing Group, (LISG), considered the case and agreed that it did not meet the criteria for a serious case review. However, group members agreed that lessons needed to be learned and so it was agreed that the case should be the subject of a learning event and that any learning would inform action plans for both the BBSCB and individual agencies.

The report outlines how the event was designed, the findings from the day and concludes with a summary of recommendations. Click on this link for the audit report on JS.

Multi-agency audit undertaken by the Performance and Audit Group in regards to Transitions

View the recent multi-agency audit undertaken by the BBSCB Performance and Audit Group in regards to Transitions.

One of the findings of the Patrick Serious Case Review was:

“The systems and processes around transition within and between Children’s and Adults’ Services in Social Care and in Health were not robust nor consistently applied.”

It is reassuring to see that this audit demonstrates that for those young people entering and in transition from children’s to adults’ services significant improvements have been made.

Multi-agency Audit Overview report of children who were the subject of repeat child protection (CP) plans under the category of neglect

This report provides an overview of Bedford Borough Safeguarding Children Board's peer audit undertaken in January/February 2015.The focus of the audit was children and young people who were the subject of repeat child protection (CP) plans under the category of neglect.

A dip sample of 3 sibling groups, each case had at least 3 agencies involved and the children and young people ranged from 4 months to 16 years. In addition the sample reflected different cultural backgrounds and included children with disabilities.

Voice of the Child Audit

This report provides an overview of Bedford Borough Safeguarding Children Board’s (BBSCB) Voice of the Child Audits undertaken between September 2014 and December 2014 and a Review Report compiled by Safeguarding and Quality Assurance at Bedford Borough Council.

The focus of this audit is to explore whether the voice of the child is heard by Bedford Borough agencies during their work with children and families. The audit relied on professional judgement of the auditor who should be guided by their own agency’s policies and standards as well as the Bedford Borough Safeguarding Children Board Procedures.

Auditors were asked to summarise their agencies individual case audits drawing out key themes and providing examples of good practice which can be shared across agencies. Click on this link to view the report

Powerpoint presentation

In preparation for the event on the 26 February 2014 we are asking that you disseminate the attached power point presentation to your frontline practitioners for their information and discussion. The presentation outlines the learning from 3 recent Serious Case Reviews in respect of Daniel Pelka, Keanu Williams and 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. View the presentation.

National learning from Serious Case Reviews

The NSPCC thematic briefings highlight the learning from serious case reviews that are conducted when a child dies or is seriously injured and abuse or neglect are suspected. Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews. So please read and share these with colleagues and your teams.

Thematic briefings highlight the learning from case reviews that are conducted when a child dies or is seriously injured and abuse or neglect are suspected.

Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews. Visit the NSPCC website for more information.

The NSPCC's Knowledge and Information Service has published a summary of learning from serious case reviews for all professionals working in the health sector. This is an overview which draws on the collective findings from three briefings we published aimed at primary healthcare teams, paediatrics and A&E and perinatal healthcare teams.

NSPCC: Health: learning from case reviews 17 December 2015

Further information

Other local case reviews and audits

These are the messages from multi-agency audits undertaken by BBSCB and CBSCB.

Hidden men learning from case reviews

NSPCC most recent briefing provides a summary of risk factors and learning for improved practice around ‘hidden’ men.
Local and National SCR reports can be found on the Serious Case Review page.