2. Serious Case Reviews

For amendments and updates, see the Amendments & Archives.

This chapter is currently under review.

2.1 Criteria

Caption: Criteria table

Criteria for Notifiable Incidents


A notifiable incident is an incident involving the care of a child which meets any of the following criteria:

  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected;
  • A looked after child has died (including cases where abuse or neglect is not known or suspected); or
  • A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCP or LSCPs promptly, and within five working days of becoming aware that the incident has occurred.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

Criteria for Serious Case Reviews


The LSCP must undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) of the Local Safeguarding Children Partnerships Regulations 2006 set out the LSCP's function in undertaking reviews of serious cases and advising the authority and their partners on lessons to be learned.


A Serious Case Review must always be initiated when:

  1. Abuse or Neglect of a child is known or suspected; AND
  2. Either:
    1. The child has died; OR
    2. The child has been seriously harmed and there is cause for concern as to the way in which the authority, their partners or other relevant persons have worked together to safeguard the child.


Thus cases meeting either of these criteria must always trigger a Serious Case Review:

  1. Abuse or Neglect of a child is known or suspected AND the child has died (including by suicide); OR
  2. Abuse or Neglect of a child is known or suspected AND the child has been seriously harmed and there is cause for concern as to the way in which the authority, their partners or other relevant persons have worked together to safeguard the child. In this situation, unless it is clear that there are no concerns about inter-agency working, a Serious Case Review must be commissioned.


Additionally, even if these criteria are not met a Serious Case Review should always be carried out when:

  • A child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children's home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.
  • Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCP must commission an SCR.

Transitional Arrangements


Under the Children Act 2004, as amended by the Children and Social Work Act 2017,LSCPs, set up by local authorities, will be replaced. Under the new legislation, the three safeguarding partners (local authorities, chief officers of police, and clinical commissioning groups) must make arrangements to work together with relevant agencies (as they consider appropriate) to safeguard and protect the welfare of children in the area.

LSCPs must continue to carry out all of their statutory functions, including commissioning SCRs where the criteria are met, until the point at which safeguarding partner arrangements begin to operate in a local area.

Where an SCR has not been completed at the point the new safeguarding partner arrangements begin to operate, for example, if they have only recently been commissioned, the LSCP should seek to complete and publish the SCR within six months of the date of the decision to initiate a review, but has a maximum of 12 months to do so. The latest date for completion and publication of an SCR is 29 September 2020.

2.2 Decisions Whether to Initiate a Serious Case Review

Caption: Decisions Whether to Initiate a Serious Case Review


The LSCP for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 2.1, Criteria) for a Serious Case Review. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCP. The Chair may seek peer challenge from another LSCP Chair when considering this decision (and also at other stages in the Serious Case Review process).


The LSCP must notify Ofsted and the National Panel of Independent Experts within five working days of the Chair's decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the LSCP chair may be asked to give evidence in person to the panel.


If the Serious Case Review criteria are not met, the LSCP may still decide to commission a Serious Case Review or an alternative form of case review.

The LSCP Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCP will also want to review instances of good practice and consider how these can be shared and embedded. The LSCP should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

LSCPs should consider conducting reviews on cases which do not meet the SCR criteria. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCP may still decide to commission an SCR or they may choose to commission an alternative form of case review.

2.3 Methodology for Learning and Improvement

Caption: Methodology for Learning and Improvement


Working Together 2018 does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.


Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.


Some Examples of Models which may be considered

  • SCIE Learning Together* (LT) has been piloted and evaluated during the Working Together consultation period **and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved;
  • Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened; ***
  • Child Practice Reviews**** replaced the Serious Case Review system as the statutory guidance in Wales on 01.01.13, This process consists of several inter-related parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an Extended review which involves an additional level of scrutiny of the work of the statutory agencies;
  • Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a 'Learning Event' and 'Recall Session';
  • Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR's conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong. They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.


Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Learning and Improvement Framework Procedure, Purpose of Local Framework, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.

* Fish, S., E. Munro, and S. Bairstow, Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 2008, Social Care Institute for Excellence: London)

** Undertaking Serious Case Reviews using the Social Care Institute for Excellence (SCIE) Learning Together systems model: lessons from the pilots. March 2013.

*** Root Cause Analysis (RCA) Investigation website.

**** Protecting Children in Wales. Guidance for Arrangements for Multi-Agency Child Practice Reviews 2013.

2.4 Parallel Processes

Caption: Parallel Processes

NHS Serious Incident Investigations


When the NHS is involved in an SCR, an NHS grade 2 Serious Incident Investigation is carried out in parallel coordinated by a Designated Safeguarding Professional employed by the Clinical Commissioning Group (CCG).  The Serious Incident investigation must include all provider organisations that were involved in the child's care during the period of time under review. Lessons will be defined and recommendations and actions made with regards to NHS interdepartmental, interdisciplinary and inter-agency working as well as those for multi-agency practice.   The NHS Serious Incident Investigation must use Serious Incident RCA systems methodology, which is compliant with the principles in Working Together to Safeguard Children. The CCG Designated Safeguarding Professional coordinating the case must have an early discussion and agree with the Chair of the Safeguarding Partnership the ways in which the SI investigation can best inform the SCR whilst avoiding duplication, for example by enabling health to undertake joint interviews with the LSCP lead reviewer for the health professionals involved, and attending all SCR multi-agency review meetings and learning events.

The interface between the serious incident process and local safeguarding procedures must therefore be articulated in local multi-agency safeguarding policies and protocols. Providers and commissioners must liaise regularly with the local authority safeguarding lead to ensure that there is a coherent multi-agency approach to investigating and responding to safeguarding concerns, which is agreed by relevant partners. Partners should develop a memorandum of understanding to support partnership working wherever possible.

See Serious Incident Framework: Supporting learning to prevent recurrence, NHS England (Updated: March 2015).

Domestic Homicide Reviews


When there has been a death of an individual of 16 years or over which has, or appears to have, resulted from violence, abuse or neglect by a person to whom s/he was related to, had been in an intimate personal relationship or was a member of the same household then a Domestic Homicide Review (DHR) or Serious Incident review will be undertaken. If the deceased person was 16 – 18 years then a Serious Case Review will be undertaken, with the Domestic abuse fully considered and shared with the Community Safety Partnership. The LSCP is involved in all reviews where there are children living in the house and the findings and recommendations are shared with the LSCP.

2.5 Appointing Reviewers

Caption: Appointing Reviewers


The LSCP will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews using the Learning and Improvement Framework Procedure, Principles for a Culture of Continuous Improvement.


The lead reviewer should be independent of the LSCP and the organisations involved in the case.


The LSCP will provide the National Panel of Independent Experts (see Section 2.9, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the panel provides about the appointment/s.


Working Together 2018 does not specify the need for an independent chair for the review process: the need for this will depend on the review model selected, the complexity of the case and other local considerations. The approach should be proportionate to the scale and level of complexity of the issues being examined.

2.6 Timescale for Serious Case Review Completion

Caption: Timescale for Serious Case Review Completion


The LSCP will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

2.7 Engagement of Organisations

Caption: Engagement of Organisations


The LSCP will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.


The LSCP may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

In addition, the LSCP can require a person or body to comply with a request for information, Section 14B of the Children Act 2004.This can only take place where the information is essential to carrying out LSCP statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCPs should be mindful of the burden of requests and should explain why the information is needed.

2.8 Agreeing Improvement Action

Caption: Agreeing Improvement Action


The LSCP will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

2.9 Publication of Reports

Caption: Publication of Reports


In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCP's website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.


The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication 'will not be likely to harm the welfare of any children or Vulnerable Adults involved in the case' and consideration given on how best to manage the impact of publication on those affected by the case. The LSCP will comply with the UK General Data Protection Regulations (UK GDPR), Data Protection Act 2018 and any other restrictions on publication of information, such as court orders.


The final Serious Case Review report should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.


The LSCP will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.


The LSCP will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCP considers that a report should not be published, it should inform the panel which will provide advice. The LSCP will provide all relevant information to the panel on request, to inform its deliberations.

2.10 National Child Safeguarding Practice Review Panel

Caption: National Child Safeguarding Practice Review Panel


In 2018 National Child Safeguarding Practice Review Panel has been established (see Working Together Chapter 4). The panel reports to the relevant Government departments their views of how the system is working. LSCPs should have regard to the panel's advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.


LSCP Chairs and LSCP members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

2.11 Considerations for Local Processes

Caption: Considerations for Local Processes


  • Engagement of families, children and service users. There is an increasing body of evidence that the family members, including children, can make a valuable contribution to professional understanding;
  • Coordination with parallel review processes (that still require formal IMR's such as Domestic Homicide Reviews);
  • Publication in full of the Overview Report;
  • Appointment of a 'lead reviewer' rather than an Overview author and independent chair;
  • Auditing and monitoring of the 'programme of action' following the findings of the review;
  • Using tools which are suitable for inter agency auditing i.e. those which capture similar data and track evidence in a consistent way.

2.12 Further Information

Caption: Further Information