Local Child Safeguarding Practice Reviews

What a local Child Safeguarding Practice Review is

A local Child Safeguarding Practice Review 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 an analysis of all the contact with the child and its family, any decisions that were made, the conclusions that were drawn and any recommendations for action. 

When 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 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 to 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've 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.

Statutory guidance

The working together to safeguard children 2023 statutory guidance 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

Notification process for serious incidents

Where a local authority in England knows or suspects that a child has been abused or neglected, they must notify the Child Safeguarding Practice Review Panel if:

• the child dies or is seriously harmed in the local authority’s area
• while normally resident in the local authority’s area, the child dies or is seriously harmed outside England

The local authority must notify the panel within five working days of becoming aware that the incident has occurred. They 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.

Duty for notifications

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 (Barnsley Council, NHS South Yorkshire Integrated Care Board, and South Yorkshire Police) of any incident which they think should be considered for a Child Safeguarding Practice Review.

How notifications are made

Serious incident notification forms for local authorities to report incidents to the Panel are on GOV.UK.

Online notifications to the panel are shared with Ofsted (to inform its inspection and regulatory activity) and with the Department for Education (to enable it to carry out its functions).

Read more about the serious incident notification process.

Barnsley Child Safeguarding Practice Reviews

The most recent Child Safeguarding Practice Reviews commissioned by Barnsley Safeguarding Children Partnership are:

• Child V
• Child W
• Child X

Local deep-dive reviews

The following deep-dive reviews look at learning from cases where there was a risk of/actual harm to a child, but where this did not meet the criteria for a serious incident notification to the national panel:

• Child F
• Child K
• Child Cameron (Doncaster Safeguarding Children Partnership)

National Child Safeguarding Practice Reviews

Completed serious case reviews and local Child Safeguarding Practice Reviews are also published by other safeguarding children partnerships.

The NSPCC has developed a national repository of these reviews, so that the learning contained within them is easier to access.

Read recently published case reviews or access the national case review collection.

National thematic reviews

A common theme running throughout many national and local reviews is that of professional curiosity. You can find out about this in the professional curiosity 7 minute briefing.

Published national thematic reviews can be found on GOV.UK:

• 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
• The myth of invisible men: 7-minute briefing
• Safeguarding rapid review examples - published December 2021

Conducting national reviews

The Child Safeguarding Practice Review Panel decide whether to undertake national reviews. Where they decide to carry out a national review, the panel should:

• notify the Secretary of State
• discuss with the local safeguarding partners the potential scope and methodology of the review, including how they'll engage with those involved in the case

There may 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 hasn't been carried out but where the panel considers that the case could be helpful to a national review at some stage in the future. In these circumstances, the panel should engage with safeguarding partners to agree the conduct of the review.

Learning from reviews

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.

Any improvements should include the ways 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.

Annual report

The Child Safeguarding Practice Review Panel publish an annual report:

• Child Safeguarding Practice Review Panel: annual report 2023 to 2024
• Child Safeguarding Practice Review Panel: annual report 2022 to 2023
• Child Safeguarding Practice Review Panel: annual report 2021