Serious Case Reviews

Introduction

Statutory Guidance which underpins the work of LSCBs is very clear in its expectation that when things go wrong for children, through death or serious injury from maltreatment, there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved in order to reduce the risk of future harm to children. It is also essential that these processes should be transparent, with findings of reviews shared publicly. LSCBs need to put in place and maintain a local learning and improvement framework which is shared across local organisations that work with children and families. A high profile element of this framework is the Serious Case Review (SCR). Details of SCRs can be found in the Working Together guidance.


The role of the Independent LSCB Chair in the SCR process is significant. It is the responsibility of the LSCB Chair to make the ultimate decision about whether the LSCB should commission a SCR, or a different process for learning lessons. The LSCB Chair also has to make the final decision about whether to publish the SCR report, based on the premise that all SCRs should be published, unless there are very compelling reasons not to.

Whilst the revised Working Together 2013 guidance has introduced greater flexibility about the methodology and processes which may be used in SCRs, it has also introduced a new element to the national scrutiny of the wider SCR contribution to child protection, through the "National Panel of Independent Experts on SCRs" The Association is engaged in discussion with the Department for Education about the role of the new national panel, its interface with the Association's Peer Consultation Scheme and the exercise of LSCB Chairs' independence.

SCR Publications

Hampshire Safeguarding Board

The press release published on 11 Nov 2013 is about the survey of unpublished Serious Case Reviews and shows that local Boards aim to publish the vast majority of SCRs. The SCR publication survey also gives reasons for delays (mainly due to legal processes) and why a very small number have NOT been published. For further details, see links below:

AILC Press Release 11 Nov 2013
AILC SCR Publication Survey 11 Oct 2013
SCR Peer Consultation Scheme
AILC Position Statement re National SCR Panel (DOCUMENT LINK REQUIRED)

National SCR Panel - Frequently Asked Questions

The briefing note below, provided by the Association, provides answers to Frequently Asked Questions concerning the national panel of independent experts on SCRs. By posting this document, the Association’s intention is to support LSCBs and to provide some consistency in the relationship between LSCB Chairs and the National Panel. The answers provided are based on the experiences of LSCB Chairs and following consultation with the Department for Education.

National SCR panel - FAQs (DOCUMENT LINK REQUIRED)

The document below was provided by the DfE in June 2013 and provides instructions for LSCBs re the national SCR panel. Reference is made to this document in the FAQs above.

DfE instructions for LSCBs re SCR National Panel (DOCUMENT LINK REQUIRED)

Improving the Quality of Serious Case Reviews – very helpful documents

In 2013 the Department for Education commissioned the training of a new group of SCR authors in order to extend the cohort of potential reviewers, from which LSCBs could draw. The training was delivered by a collaboration between Sequeli, the NSPCC and Action for Children. The materials which were developed in order to deliver this training have now been made available to the Association's website and they are, in themselves, a very helpful resource. Alongside these training materials are some newly developed documents entitled:

  • LSCB commissioning materials: with knowledge and skills framework
  • LSCBs are invited to use these documents to inform their commissioning, process and publication of SCRs

These files are large, so they might take a minute or two to download, but are worth the wait!

SCR Seminar Materials, Case Law and Resources (DOCUMENT LINK REQUIRED)

Training and LSCB commissioning materials (DOCUMENT LINK REQUIRED)

Message re Copyright of Documents

Copyright of the Training and Commissioning Materials rests with the Department for Education and you should mention that when you use the materials. You must not use the material for any profit-making activity. Since much of the material is based on pre-existing Sequeli copyright, Sequeli also grants you a licence to use the materials, on the same basis that you acknowledge they are based on copyrighted Sequeli material. As above, you must not use Sequeli material for any profit-making purposes.

Should IMRs be Disclosed to Coroners?

A current High Court case is considering the disclosure IMRs to Coroners. This is relevant to all LSCBs and the Asscociation has assisted the case with the provision of 'intelligence' from across the regions.
This link will take you to a short video from the legal firm representing the LSCB directly involved in the case:

Disclosing IMRs to Coroners (DOCUMENT LINK REQUIRED)
Case example - Disclosing an IMR to Coroners (DOCUMENT LINK REQUIRED)
Legal briefing on disclosure of Coroners information (DOCUMENT LINK REQUIRED)

Interesting judgement by Information Commissioner

The Information Commissioner in Northern Ireland has upheld a decision not to publish an SCR. Whilst this concerns a Northern Ireland case, it has relevance to the rest of the UK. An article in Professional Social Work (March 2013 p14-15) discusses the decision from the Information Commissioner's Office (ICO) that it is not in the interests of families for SCRs to be published because of the distress this will cause. Click on this link and turn to page 14 to read more.

Article in PSW re Non Publication of SCR (DOCUMENT LINK REQUIRED)

Criminal Proceeding Guidance

National Policing Homicide Working Group have published a guide for Police, Crown Prosecution Service and LSCBs.

 Click here to see guide

Barriers to Learning

Kingston University’s Institute for Child-Centred Inter-professional Practice (ICCIP) was awarded a contract from the Department for Education (DfE) to undertake a small study investigating barriers to learning from Serious Case Reviews (SCRs) in order to identify ways of overcoming these barriers and ensure that any learning is embedded in policy and practice.

Click here to see the report

Learning from SCRs

At a glance thematic briefings.

Please click here Thematic Reviews

Further SCR Reading

Anonymised SCRs

An LSCB has published an SCR report, keen that lessons can be shared across all LSCB areas. All references to the geography and identifying details relating to the family, known as  Family W, have been removed from this report in compliance with a Reporting Restriction Order of the High Court, and in recognition of the need for the children concerned to have their anonymity preserved. The LSCB fully accepts the findings and recommendations of this report. It took exceptional courage for A to come forward and bring the facts of this case to light. In doing so she protected her own child and siblings from any further abuse. The links below include:

  • SCR Report
  • Executive Summary of SCR
  • Report for Department of Health, addressing issues raised by the SCR
  • Report concerning issues of Home Education, as raised by the SCR

 Click below to see the reports:

SCR Reports

SCR Reports are available below:

Click here NSPCC Search (FG LINK DOES NOT WORK)

SCR Key Facts