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1. Criteria

The LSCB must undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 set out the LSCB’s function in undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

A Serious Case Review must always be initiated when:

  • Abuse or Neglect of a child is known or suspected; AND
  • Either:
    • The child has died; OR
    • The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

Thus cases meeting either of these criteria must always trigger a Serious Case Review:

  1. Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
  2. Abuse or Neglect of a child is known or suspected AND the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In this situation, unless it is clear that there are no concerns about inter-agency working, a Serious Case Review must be commissioned.

Additionally, even if these criteria are not met a Serious Case Review should always be carried out when:

  • A child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.
  • Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCB must commission an SCR.

“Seriously harmed” in the context of regulation 5(2)(b)(ii) above includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • a potentially life-threatening injury;
  • serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred.

The following questions may also help in deciding whether a case should be the subject of an SCR. The answer ‘yes’ to one or more of these questions is likely to indicate that a SCR could yield useful lessons:

  • Was there clear evidence of a child having suffered, or been likely to suffer, Significant Harm that was:
    • not recognised by organisations or professionals in contact with the child or perpetrator or
    • not shared with others or
    • not acted on appropriately?
  • Was the child abused or neglected in an institutional setting (for example, school, nursery, children’s or family centre, YOI, STC, immigration removal centre, mother and baby unit in a prison, children’s home or Armed Services training establishment)?
  • Was the child abused or neglected while being Looked After by the local authority?
  • Was the child a member of a family that has recently moved to the UK, for example as Asylum Seekers or temporary workers?
  • Did the child suffer harm during an Unauthorised Absence from an institution, or having run away from home or other care setting?
  • Does one or more agency or professional consider that its concerns about a child’s welfare were not taken sufficiently seriously, or acted on appropriately, by another?
  • Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding children procedures which go beyond the handling of this case?
  • Was the child the subject of a Child Protection Plan at the time of the incident, or had they previously been the subject of a plan or on the child protection register?
  • Does the case appear to have implications for a range of agencies and/or professionals?
  • Does the case suggest that the LSCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately promulgated, understood or acted on?
  • Are there any indications that the circumstances of the case may have national implications for systems or processes, or that it is in the public interest to undertake a SCR?

2. Decisions Whether to Initiate a Serious Case Review

The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 1, Criteria) for a Serious Case Review. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).

The LSCB must notify Ofsted and the National Panel of Independent Experts within five working days of the Chair’s decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the LSCB chair may be asked to give evidence in person to the panel.

If the Serious Case Review criteria are not met, the LSCB may still decide to commission a Serious Case Review or an alternative form of case review.

3. Methodology for Learning and Improvement

Working Together 2015 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

Some Examples of Models which may be considered

  • SCIE Learning Together* (LT) has been piloted and evaluated during the Working Together consultation period **and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved;
  • Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened; ***
  • Child Practice Reviews**** replaced the Serious Case Review system as the statutory guidance in Wales on 01.01.13, This process consists of several inter-related parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an Extended review which involves an additional level of scrutiny of the work of the statutory agencies;
  • Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’;
  • Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR’s conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong. They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.

Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Learning and Improvement Framework Procedure, Purpose of Local Framework, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.

* Fish, S., E. Munro, and S. Bairstow, Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 2008, Social Care Institute for Excellence: London)

** Undertaking Serious Case Reviews using the Social Care Institute for Excellence (SCIE) Learning Together systems model: lessons from the pilots. March 2013.

*** Root Cause Analysis (RCA) Investigation website.

**** Protecting Children in Wales. Guidance for Arrangements for Multi-Agency Child Practice Reviews 2013.

4. Parallel Processes

NHS Serious Incident Investigations

When the NHS is involved in an SCR, an NHS grade 2 Serious Incident Investigation is carried out in parallel coordinated by a Designated Safeguarding Professional employed by the Clinical Commissioning Group (CCG).  The Serious Incident investigation must include all provider organisations that were involved in the child’s care during the period of time under review. Lessons will be defined and recommendations and actions made with regards to NHS interdepartmental, interdisciplinary and inter-agency working as well as those for multi-agency practice.   The NHS Serious Incident Investigation must use Serious Incident RCA systems methodology, which is compliant with the principles in Working Together to Safeguard Children 2015. The CCG Designated Safeguarding Professional coordinating the case must have an early discussion and agree with the Chair of the Safeguarding Board the ways in which the SI investigation can best inform the SCR whilst avoiding duplication, for example by enabling health to undertake joint interviews with the LSCB lead reviewer for the health professionals involved, and attending all SCR multi-agency review meetings and learning events.

The interface between the serious incident process and local safeguarding procedures must therefore be articulated in local multi-agency safeguarding policies and protocols. Providers and commissioners must liaise regularly with the local authority safeguarding lead to ensure that there is a coherent multi-agency approach to investigating and responding to safeguarding concerns, which is agreed by relevant partners. Partners should develop a memorandum of understanding to support partnership working wherever possible.

See Serious Incident Framework: Supporting learning to prevent recurrence, NHS England (Updated: March 2015).

Domestic Homicide Reviews

When there has been a death of an individual of 16 years or over which has, or appears to have, resulted from violence, abuse or neglect by a person to whom s/he was related to, had been in an intimate personal relationship or was a member of the same household then a Domestic Homicide Review (DHR) or Serious Incident review will be undertaken. If the deceased person was 16 – 18 years then a Serious Case Review will be undertaken, with the Domestic Violence fully considered and shared with the Community Safety Partnership. The LSCB is involved in all reviews where there are children living in the house and the findings and recommendations are shared with the LSCB.

5. Appointing Reviewers

The LSCB will appoint one or more suitable individuals to lead the Serious Case Review and should be independent of the LSCB and the organisations involved in the case.

The LSCB will provide the National Panel of Independent Experts (see Section 10, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.

Working Together 2015 does not specify the need for an independent chair for the review process: the need for this will depend on the review model selected, the complexity of the case and other local considerations. The approach should be proportionate to the scale and level of complexity of the issues being examined.

6. Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

7. Engagement of Organisations

The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

8. Agreeing Improvement Action

The LSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings.

9. Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months ( and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Vulnerable Adults involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

The LSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, it should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.

10. National Panel of Independent Experts on Serious Case Reviews

Since 2013 a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews has been in place. The role of the panel is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through the publication of final SCR reports. The panel reports to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.

LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

11. Considerations for Local Processes

  • Engagement of families, children and service users. There is an increasing body of evidence that the family members, including children, can make a valuable contribution to professional understanding;
  • Coordination with parallel review processes (that still require formal IMR’s such as Domestic Homicide Reviews);
  • Publication in full of the Overview Report;
  • Appointment of a ‘lead reviewer’ rather than an Overview author and independent chair;
  • Auditing and monitoring of the ‘programme of action’ following the findings of the review;
  • Using tools which are suitable for inter agency auditing i.e. those which capture similar data and track evidence in a consistent way.

12. Further Information

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