Serious Case Reviews

As soon as a serious case review is underway there are important lessons to be learned. These lessons could have direct implications for the way in which professionals work. This page will be dedicated to the effective dissemination of these lessons in order to help ensure such incidents do not happen again.

When a child dies (including death by suicide), and abuse or neglect are known or suspected to be a factor in the death, local organisations should consider immediately whether there are other children at risk of harm who require safeguarding (e.g. siblings, other children in an institution where abuse is alleged).

Thereafter, organisations should consider whether there are any lessons to be learnt about the ways in which they work together to safeguard and promote the welfare of children.

Consequently, when a child dies in such circumstances, the Local Safeguarding Children Board (LSCB) should always conduct a serious case review into the involvement with the child and family of organisations and professionals.

Additionally, the LSCB should always consider whether a serious case review should be conducted where:

• a child sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect; or
• a child has been subjected to particularly serious sexual abuse; or
• a parent has been murdered and a homicide review is being initiated; or
• a child has been killed by a parent with a mental illness; or
• the case gives rise to concerns about inter-agency working to protect children from harm.

Purpose of Serious Case Reviews

• Establish whether there are lessons to be learnt from the case about the way in local professionals and organisations work together to safeguard and promote the welfare of children.
• Identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result; and
• as a consequence, improve inter-agency working and better safeguard and promote the welfare of children.
• Serious case reviews are not inquiries into how a child died or who is culpable.  That is a matter for Coroners and Criminal Courts respectively to determine, as appropriate.