Barnsley Safeguarding Children Board

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.

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 –

  1. The child dies or is seriously harmed in the local authority’s area; or
  2. 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

*In respect of Local Safeguarding Children Boards, 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 (BMBC), any Clinical Commissioning Groups (Barnsley CCG) operating in the area and the Chief Officer of Police (SYP) - 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 BSCB operates or its sub committees.

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 most recent Serious Case Reviews commissioned by Barnsley Safeguarding Children Board.

Child R

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. 

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.