Serious Case Review
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. Conversely, 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.
When a child dies, and abuse or neglect are known or suspected to be a factor in the death, local agencies should consider immediately whether there are other children at risk of harm who need safeguarding (e.g. siblings, other children in an institution where abuse is alleged). Thereafter, agencies should consider whether there are any lessons to be learned from the tragedy about the ways in which they work together to safeguard children. This is called a ‘Serious Case Review’.
The LSCP Critical Incident Group is a sub group of the LSCP and is responsible for establishing the need for a Serious Case Review, overseeing the review process and for ensuring that recommendations are implemented as required by statutory guidance within Chapter 4 Working Together to Safeguard Children July 2018
Membership of the Critical Incident Group (CIG) is made up of representatives of the Liverpool Safeguarding Children Partnership.
When a child dies, and abuse or neglect are known or suspected to be a factor in the death, the LSCP CIG Group consider immediately whether there are other children at risk of harm who require safeguarding (For example siblings, other children in an institution where abuse is alleged).
Thereafter, the LSCP review process consider whether there are any lessons to be learned 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 LSCP always conducts a serious case review into the involvement with the child and family of organisations and professionals.
Additionally, the LSCP always considers 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
- has been subjected to particularly serious sexual abuse, or
- their parent has been murdered and a homicide review is being initiated, or
- the 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.
The purpose of serious case reviews is to:
- establish whether there are lessons to be learned from the case about the way in which 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 upon, and what is expected to change as a result;
- and as a consequence, to improve inter-agency working and better safeguard and promote the welfare of children.
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.
Publication of Reports
Working Together 2018 details the requirements of Local Safeguarding Children Partnership Boards to publish serious case reviews as follows;
‘All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCP’s website for a minimum of 12 months. Thereafter, the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs.’
Response to Serious Case Reviews
Working Together 2018 details the requirements of Local Safeguarding Children Partnership Boards to publish information about actions which have been taken in response to the findings of serious case reviews as follows;
‘LSCPs should publish, either as part of the SCR report or in a separate document, information about: actions which have already been taken in response to the review findings; the impact these actions have had on improving services; and what more will be done.’
NB: Any review undertaken before 2019 was under the former Liverpool Safeguarding Children Board and following Working Together 2015 guidance. Subsequent reviews are undertaken by the Liverpool Safeguarding Children Partnership and use the Working Together 2018 guidance.