Serious Case 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.
When a child dies, and abuse or neglect are known or suspected to be a factor in the death, Barnsley Safeguarding Children Board will always undertake a Serious Case Review; firstly to consider whether there may be other children at risk of harm, such as siblings, and secondly to get a better understanding of how agencies involved with the child worked together, how and why decisions were made, and what lessons can be learned.
What is a serious case 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 serious case reviews take place?
Serious Case 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 serious case reviews take place?
Serious Case 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 Serious Case 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 Boards have a duty to publish an anonymised version of the Overview Report and Executive Summary of any Serious Case Reviews that they have conducted. This will include an overview of the case, the terms of reference, conclusions drawn and any recommendations made.
Serious Case Reviews are a major element of the Safeguarding Board's Learning and Improvement Framework which sets out how the Board will learn lessons from tragic events and put in place measures to reduce the likelihood of such events reoccurring.
Published serious case reviews (Barnsley)
The links below provide access to the most recent Serious Case Reviews commissioned by Barnsley Safeguarding Children Board.
Published serious case reviews (national)
Completed Serious Case Reviews are also published by other Safeguarding Children Boards. The NSPCC, in collaboration with the Association of Independent LSCB Chairs has developed a national repository of published Serious Case Reviews so that the learning contained within them is easier to access. It has also published a thematic briefing that pulls together and highlights the learning from case reviews into the death or serious injury of a child where parental substance misuse was a key factor, based on case reviews published since 2010.
Below are links to some recent high profile Reviews that may contain relevant lessons for Barnsley.
Coventry Safeguarding Children Board - Daniel Pelka
Wakefeld Safeguarding Children Board - Child Christine
Birmingham Safeguarding Children Board - Assault on a child in a nursery setting
Bradford Safeguarding Children Board - Hamzah Khan
Rochdale Safeguarding Children Board - Two Reviews into Child Sexual Exploitation
Derby Safeguarding Children Board - Family of six children in Derby
National findings from serious case reviews
Ofsted no longer evaluate Serious Case Reviews as set out in Working Together to Safeguard Children 2015, in line with recommendations from the Munro Review. However they have previously published a report, Learning Lessons from Serious Case Reviews 2009 - 2010, that provides an analysis of 147 serious case reviews completed between 1 April 2009 and 31 March 2010.
In addition, a report published in October 2011 Ages of concern: learning lessons from serious case review provides a thematic analysis of 482 serious case reviews evaluated between 1 April 2007 and 31 March 2011. The main focus of this report is on the reviews that concerned children in two age groups: babies less than one year old and young people aged 14 or above.
Serious case reviews national panel report
In June 2013 a National Panel of Independent Experts was established to support Safeguarding Boards in ensuring that appropriate action is taken to learn from serious incidents in cases where the criteria are met and to ensure that lessons learned are shared through publication of the final report. In July 2014 the Panel published its first annual report, in which it comments on decision making by Safeguarding Boards and the quality of published Serious Case Reviews.The NSPCC produces a useful series of briefing papers containing findings from Serious Case Reviews against various themes.