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Background to Serious Case Reviews (SCRs)

As of April 2019, Local Safeguarding Children Boards were abolished according to the Children and Social Work Act 2017 and Working Together 2018, and new and local Multi-Agency Safeguarding Arrangements (MASA) were implemented. Serious Case Reviews (SCR) also changed to Child Safeguarding Practice Reviews (CSPR), the criteria for undertaking a CSPR has been slightly amended from the SCR criteria and Rapid Reviews have been introduced

The Thematic Review

The review focused on the SCRs and CSPRs completed locally between 2019 to 2021 identifying parental and child factors and ‘professional practice themes’. Both the Peterborough and Cambridgeshire electronic recording systems were accessed during November 2021 to December 2021 and either full SCRs and CSPRs or their executive summaries, published from 2019 were located.


For the period from 2019 – 2021 four case reviews in total were completed consisting of one CSPR and three SCRs. During 2019 to 2021 two of the case reviews were referred by the police, one by children social care and one by Cambridgeshire Community Services NHS Trust.

Parental Factors

50% of the cases within this sample had all three parental factors of domestic violence, parental mental health, and substance misuse present. Brandon et al’s (2020) triennial report on SCRs from 2014-2017 makes reference to these three factors as being separately present in the majority of SCRs with domestic abuse being the main factor (59%), followed by parental mental health (55%) and then substance/ alcohol misuse (36%) (Brandon et al, 2020, pp 50-51). The National Panel in their 2021 report had similar findings in SCR/CSPR cases taken from January 2020 – December 2020 where 46% of cases had domestic violence as a factor, followed by 28% parental mental health and substance misuse 23.7%+18% alcohol misuse factors (Child Safeguarding Practice Review Panel 2021, pp22-23)

Other parental factors found within our local reviews included; parents being known to social care, having had adverse childhood experiences and parents subjected to criminal convictions. These were also parental factors that stood out in both the research reports based on the cases of the children who featured within SCR/ CSPR cases (Brandon et al 2020, p51; Child Safeguarding Practice Review Panel 2021, p22).

Child Factors

Of the four children involved within our local SCR/CSPRs two were in their teenage years and two were babies. These are similar findings to both the National Panels research (2021) and Brandon et al (2020) research in that most SCR/CSPR cases were in relation to children under the age of a year and children in their teenage years (adolescents) (Brandon et al, 2020 p 43; Child Safeguarding Practice Review Panel 2021: p15).

Professional Practice Themes

Good Practice

In 50% of the local SCR/CSPR we reviewed, good practice was identified within assessments, risk sensible decisions / plans to mitigate risk, making appropriate referrals for agency involvement, having a responsive approach from professionals and supportive advice offered by agencies.

Areas to Improve on

In 100% of the cases reviewed a ‘lack of sharing information’ was the top theme. Lack of sharing information within this sample of cases referred to not sharing safeguarding information between agencies working with the children and not sharing information with parents. This is an increase on the previous thematic analysis report where 59% of cases recorded this theme (Cambridgeshire and Peterborough Children’s Partnership Board (2020)).

In 75% of the child review cases the following professional themes were present:

  • Delay in the case / Delayed Decisions made/ Delayed Support given
  • Agencies not Working Together
  • Not all relevant Professionals invited/Present at strategy meetings
  • Lack of Recording on file and in assessments
  • Lack of Professional Challenge between agencies, professionals and towards parents
  • Not finding out the Lived Experience of the child
  • Not using Authoritative Practice where this would have been helpful
  • Disguised Compliance / Non-compliance of parents towards professionals and agencies

It is interesting to note that ‘authoritative practice’ did not feature within the previous thematic review but is present within this review. Arguably, this is a relatively new term featuring more recently within the SCR research of Sidebotham et al 2016 and Brandon et al 2020. Sidebotham et al 2016 describes utilising ‘authoritative practice’ within complex cases as practice by professionals for keeping the child at the centre of by exercising their professional judgement and “encouraging professional curiosity and challenge from a supportive base whilst taking responsibility for their role in the safeguarding process, while respecting and valuing the roles of others” (Sidebotham et al, 2016; p18).

Further Information:

Safeguarding Partnership Board Website:

Safeguarding Partnership Board Training:

Virtual Briefings, Briefings and Training Resources:

Virtual Briefings (Sways) | Cambridgeshire and Peterborough Safeguarding Partnership Board (

Lived Experience of the Child Practice Guidance | Cambridgeshire and Peterborough Safeguarding Partnership Board (

Professional Curiosity / Opportunities to be Curious Briefing – UPDATED | Cambridgeshire and Peterborough Safeguarding Partnership Board (

Child Safeguarding Practice Reviews / Serious Case Reviews:


HM Government (2018). Working Together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children.

HM Government (2017). Children and Social Work Act 2017 Available at:

Brandon, M., Sidebotham, P., Belderson, P., Cleaver, H., Dickens, J., Garstang, J., Harris, J., Sorensen, P., and Wate, R. (2020). Complexity and challenge: a triennial analysis of SCRs 2014-2017. Department for Education.

Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2020) Thematic Review of the Professional Themes found within Serious Case Review from 2006 – 2019. CPSCPB

Child Safeguarding Practice Review Panel (2020a) Annual Report 2020: Child Safeguarding Practice Review Panel: annual report 2020 – GOV.UK (

Dickens, J., Taylor, J., Garstang, J., Hallett, N., Rennolds N., and Sorensen, P. (2021) Annual review of LCSPRs and rapid reviews. The Child Safeguarding Practice Review Panel

Sidebotham. P, Brandon. M, Bailey. S, Belderson. P, Dodsworth. J, Garstang. J, Harrison. E, Retzer, A. and Sorensen.P.(2016). Pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. Department for Education : University of Warwick : University of East Anglia

April 2022

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