Learning from serious case reviews

A serious case review (SCR) is a local enquiry carried out where a child has died or been seriously harmed and abuse or neglect are known or suspected, and there is cause for concern about professionals working together. The aim of the study is to provide evidence of key issues and challenges for agencies working individually and together in these cases.

Key findings

What do SCRs tell us about the child protection system?

  • There has been an increase in the number of SCRs carried out since 2012, but this has been against a backdrop of a steady year-on-year increase in child protection activity. There has been no change in the number of child deaths linked directly to maltreatment and, if anything, a reduction in the fatality rates for all but the older adolescent age group.
  • Only a small minority of children at the centre of a SCR (12%) had a current child protection plan at the time of their death or serious harm. This is at a time when nationally numbers of children with a child protection plan have been rising dramatically.
  • While fewer than half of SCRs revealed current involvement with children’s social care, almost two thirds of the children had at some point been involved with Children’s Social Care at least to the level of child in need. It is apparent that many of these children’s cases had either been closed too soon or lacked the ongoing support services and monitoring that the children and families needed.
  • While these most recent SCRs suggest there may be a good awareness of risk factors among staff across universal, early help and specialist services, they also suggest that practitioners are not always rigorous in assessing and following through on all identified risks including domestic abuse. Where the threshold for children’s social care involvement is not met, there may be little analysis of risks of harm.
  • Throughout the review there were examples of creative and effective child safeguarding. For many of the children, the harms they suffered occurred in spite of all the work that professionals were doing to support and protect them.
  • The review’s authors suggest an approach that steers away from trying to pronounce on whether a death or serious harm could have been predicted or prevented, to acknowledging that there is always room for learning and improvement in our systems. It is important to identify those lessons, disseminate the learning, and implement appropriate actions for improvement.
  • The report suggests an approach that recognises that children are harmed within contexts of risk and vulnerability and that there are many opportunities for prevention and protection, even without being able to accurately predict which children may be harmed, when or in what manner.

The Triennial Review suggests that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals:

  • Effective communication is central to all safeguarding practice.
  • All national guidance and legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people.
  • The Data Protection Act 1998 and Human Rights Act 1998 are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately. (It should be noted that since this Triennial Review, there has been new GDPR and Data Protection Legislation – however, the new Information Sharing: Advice for practitioners providing safeguarding services 2018 legislation confirms this statement)
  • Child protection agencies must feedback promptly to referrers and others participating in safeguarding.
  • Information must be triangulated and verified. This involves seeking independent confirmation of parents’ accounts and triangulating information between professionals.
  • Practitioner forums may provide opportunities for professionals to discuss cases and share information in a safe environment.

The NSPCC produces thematic briefings highlighting the learning from case reviews.

The briefings focus on different topics or learning for different professional groups such as GPs and primary healthcare teams.

Not Seen, Not Heard

The Care Quality Commission (CQC) in England also inspect regions to assess how the safeguarding services work together to protect children. Their July 2016 report Not Seen, Not Heard reflects the lessons from 50 inspections and finds that children have a variable experience of services.

The report recommendations were:

  • children and young people must be actively engaged in their care
  • services must ensure their focus is on outcomes
  • more is done to identify children at risk of harm
  • children and young people must have access to the emotional and mental health support they need