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 2023

Working Together to Safeguard Children 2023 states:

The purpose of serious child safeguarding case reviews, at local and national level, is to identify improvements that can be made to safeguard and promote the welfare of children. Learning is relevant locally but 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. There are other processes for that purpose, including employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside a review or at a later stage. Employers should consider whether any disciplinary action should be taken against practitioners whose conduct and/or practice falls below acceptable standards. They should then refer to their regulatory body as appropriate.

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). At a local level the responsibility lies with the safeguarding partners.

The panel is responsible for identifying and overseeing the review of serious child safeguarding cases which, in its opinion, raise issues that are complex or of national importance. It should also oversee the system of national and local reviews and how effectively it is operating.

As outlined in chapter 2, the safeguarding partners play an integral role in establishing a system of learning and reflection locally. Safeguarding partners must:

  • identify and review serious child safeguarding cases which, in their opinion, raise issues of importance in relation to their area
  • commission and oversee the review of those cases if they consider it appropriate

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'. These are:

  • The local authority (Barnsley Council).
  • Any clinical commissioning groups (NHS South Yorkshire Integrated Care Board) operating in the area.
  • The Chief Officer of Police (South Yorkshire Police).

These organisations then 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. This 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. Especially 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. This 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. These 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.

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. This is 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. It should also show 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. They should do this with a view to considering how identified improvements should be implemented locally. It should include 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: