Local Child Safeguarding Practice Reviews play a vital role in helping local professionals and organisations to continually improve the way they work, individually or together, to keep children safe and free from harm.
Working Together to Safeguard Children 2018
The purpose of reviews of serious child safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families and for the government and policymakers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.
Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage.
The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel (the Panel) and at local level with the safeguarding partners.
The Panel is responsible for identifying and overseeing the review of serious child safeguarding cases which, in its view, raise issues that are complex or of national importance. The Panel should also maintain oversight of the system of national and local reviews and how effectively it is operating.
Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They must commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken.
Changes to notification process of serious incidents
This is the formal process of notifications to the Child Safeguarding Practice Review Panel.
In respect of Serious Case Reviews, amendments have been made to 16C(1) of the Children Act 2004 by the Children and Social Work Act 2017.
There is now a duty on local authorities to notify incidents to the Child Safeguarding Practice Review Panel which became operational in June 2018.
Where a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if:
- The child dies or is seriously harmed in the local authority’s area; or
- While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.
The local authority must notify any event that meets the above criteria to the Panel. They should do so within five working days of becoming aware that the incident has occurred. The local authority should also report the event to the safeguarding partners in their area (and in other areas if appropriate) within five working days.
The local authority must also notify the Secretary of State and Ofsted where a looked after child has died, whether or not abuse or neglect is known or suspected.
The duty to notify events to the Panel rests with the local authority. Others who have functions relating to children should inform the safeguarding partners* of any incident which they think should be considered for a child safeguarding practice review. Contact details and notification forms for local authorities to notify incidents to the Panel are available from the notification to Ofsted page on GOV.UK.
Online notifications to the Panel will be shared with Ofsted (to inform its inspection and regulatory activity) and with DfE to enable it to carry out its functions.
The above is covered in greater depth in Working Together to Safeguard Children 2018 Ch 4. Improving Child Protection and Safeguarding Practice.
Find out about the serious incident notification process.
*In respect of Local Safeguarding Children Boards (LSCB), the Act effectively abolishes Local Safeguarding Children Boards, removing the Children Act 2004 duties relating to them. In their place, it puts duties on three 'safeguarding partners' - the local authority (Barnsley Council), any clinical commissioning groups (NHS South Yorkshire Integrated Care Board) operating in the area, and the Chief Officer of Police (South Yorkshire Police) - to make safeguarding arrangements that respond to the needs of children in their area. In practice, in Barnsley, it is not envisaged that this will fundamentally change the way the Barnsley Safeguarding Children Partnership operates or its sub committees.
What is a Local Child Safeguarding Practice Review?
This is the formal process that brings together information from all the agencies involved with the child and its family leading up to the child's death. From these records, a complete picture of the case can be drawn up in the form of a final overview report, which includes analysis of all contact with the child and its family, any decisions that were made, the conclusions that were drawn and any recommendations for action.
When do Local Child Safeguarding Practice Reviews take place?
Child Safeguarding Practice Reviews are always undertaken when a child dies (including suicide), and abuse or neglect is known or suspected to be a factor in the death.
They can also be undertaken where:
- a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect
- a child has been seriously harmed as a result of being subjected to sexual abuse
- a parent has been murdered and a domestic homicide review is being initiated under the Domestic Violence Act 2004
- a child has been seriously harmed following a violent assault perpetrated by another child or adult
- the case gives rise to concerns about inter-agency working to protect children from harm.
Why do Child Safeguarding Practice Reviews take place?
Child Safeguarding Practice Reviews are not inquiries into how a child died or was seriously harmed, or into who is to blame. These are matters for coroners and criminal courts to determine as appropriate. The focus of Child Safeguarding Practice Reviews is to identify improvements to practice to safeguard and promote the welfare of children by:
- establishing what lessons need to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children
- identifying clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result
- improving intra- and inter-agency working and better safeguard and promote the welfare of children.
Local Safeguarding Children Partnerships have a duty to publish an anonymised version of the Overview Report and Executive Summary of any Child Safeguarding Practice Reviews that they have conducted. This will include an overview of the case, the terms of reference, conclusions drawn and any recommendations made.
Child Safeguarding Practice Reviews are a major element of the safeguarding partnership's learning and improvement framework which sets out how the partnership will learn lessons from tragic events and put in place measures to reduce the likelihood of such events reoccurring.
Published Child Safeguarding Practice Reviews (Barnsley)
The most recent Child Safeguarding Practice Reviews commissioned by Barnsley Safeguarding Children Partnership are:
Deep dive reviews
The following 7-minute briefings look at learning from cases where there was a risk of/actual harm to a child, which did not meet the criteria for a serious incident notification to the national panel.
These 7-minute briefings come from deep dive reviews where there were learning opportunities for improved partnership working.
- Child F
- Child K
- Child Cameron: South Yorkshire 7-minute briefing (Doncaster Safeguarding Children Partnership)
Published Serious Case Reviews and Local Child Safeguarding Practice Reviews (national)
Completed Serious Case Reviews and completed Local Child Safeguarding Practice Reviews are also published by other Safeguarding Children Partnerships.
The NSPCC, in collaboration with the National Panel has developed a national repository of published Serious Case Reviews and Local Child Safeguarding Practice Reviews so that the learning contained within them is easier to access.
National findings from Local Child Safeguarding Practice Reviews
The National Panel should take decisions on whether to undertake national reviews and communicate their rationale appropriately, including to families. The National Panel should notify the Secretary of State when a decision is made to carry out a national review.
If the National Panel decides to undertake a national review they should discuss with the local safeguarding partners the potential scope and methodology of the review and how they will engage with them and those involved in the case.
There will be instances where a local review has been carried out which could then form part of a thematic review that the National Panel undertakes at a later date. There may also be instances when a local review has not been carried out but where the National Panel considers that the case could be helpful to a national review at some stage in the future. In such circumstances, the National Panel should engage with safeguarding partners to agree the conduct of the review.
Local Child Safeguarding Practice Reviews – National Panel Report and Thematic National Reviews
The safeguarding partners should take account of the findings from their own local reviews and from all national reviews, with a view to considering how identified improvements should be implemented locally, including the way in which organisations and agencies work together to safeguard and promote the welfare of children. The safeguarding partners should highlight findings from reviews with relevant parties locally and should regularly audit progress on the implementation of recommended improvements. Improvement should be sustained through regular monitoring and follow up of actions so that the findings from these reviews make a real impact on improving outcomes for children.
Published National Thematic Reviews can be found on GOV.UK:
- A common theme running throughout many recent national and local reviews is that of professional curiosity. To find out more, please see the following 7 minute briefing.
- Safeguarding children at risk from criminal exploitation - published 4 March 2020
- Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm - Published July 2020
- The Myth of Invisible Men: Safeguarding children under 1 from non-accidental injury caused by male carers - Published September 2021
- Child Safeguarding Practice Review Panel: Annual report 2023 - Published December 2021
- Safeguarding rapid review examples - Published December 2021
- The Myth of Invisible Men: 7-minute briefing