Serious Case Reviews – resources for practitioners
Serious Case Reviews (SCR) play a vital role in helping practitioners and organisations to continually improve the way they work, individually or together, to keep children and young people safe and free from harm.
A Serious Case Review (SCR) is the formal process that brings together information from all the agencies involved with a child and their family leading up to the incident. From these records, a complete picture of the case can be drawn up in a report, which includes analysis of all contact with the child and family, any decisions that were made, the conclusions made and any recommendations for action.
When and why do Serious Case Reviews take place?
SCRs are carried out for every case where abuse or neglect is known or suspected and either:
- a child has died or;
- a child has been seriously harmed and there are concerns about how organisations or professionals worked together to protect the child.
The full criteria are specified in Working Together to Safeguard Children.
A SCR 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 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.
SCRs 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;
- 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 SCRs take place?
The purpose of SCRs is to identify improvements which are needed and to consolidate good practice. SCRs are not enquiries into how a child died or was seriously harmed, or into who is to blame. These are matters for the coroners and criminal courts as appropriate.
SCRs identify improvements to practice to safeguard and promote the welfare of children by:
- establishing what lessons need to be learned from the case about the way in which 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.
The findings from SCRs are translated into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.
Local Safeguarding Children Boards have a duty to publish an anonymised version of the SCR Report. This will include an overview of the case, the terms of reference, conclusions drawn and any recommendations made.
SCR reports are published for a minimum of twelve months; all reports published prior to this should be available from the NSPCC SCR repository.
Serious Case Reviews are a major element of our learning and improvement framework which sets out how we will learn lessons from tragic events and put in place measures to reduce the likelihood of such events reoccurring. Working Together 2015 requires a LSCB to publish information about actions which have been taken in response to the findings of serious case reviews.
MSCB SCR Referral Process
If an individual or agency feels a case should be referred for a SCR they should complete the MSCB SCR Referral Form (March 2018 onwards) and partner agencies are asked to contribute any information they may have about the case. This is then screened by the SCR Subgroup to determine if it meets the criteria.
If you become aware of an incident or case:
- discuss it with a senior manager and/or your agency SCR Subgroup member;
- if required, your agency SCR Subgroup member or a senior manager should hold an initial discussion with the MSB Review Coordinator;
- the SCR Subgroup member or senior manager should complete the SCR Referral form and submit it to the MSB Review Coordinator by email to email@example.com
The MSCB SCR Referral Form (March 2018 onwards) replaces any previously used forms.
If you have any queries please contact the MSB Review Coordinator or the MSB Business Unit.
COMPLETED FORMS SHOULD BE SENT TO THE MSB INBOX – firstname.lastname@example.org
Carrying out MSCB Serious Case Reviews
Practitioners involved with the child or family in the case are fully involved in SCRs. They are invited to contribute their perspectives without fear of being blamed for actions they took in good faith.
Families are also invited to contribute to SCRs. We work hard to make clear to them how they are going to be involved and mange their expectations appropriately and sensitively. This is important for ensuring that the child is at the centre of the process.
SCRs should be conducted in a way which:
- 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;
- is transparent about the way data is collected and analysed; and
- makes use of relevant research and case evidence to inform the findings.
The MSCB follows the principles of the North West Learning and Improvement Framework, within the Greater Manchester Safeguarding Partnership (GMSP) procedures which can be found at greatermanchesterscb.proceduresonline.com
MSCB published Serious Case Reviews
All current and historical MSCB publications can be found via the NSPCC National Case Reviews Repository
Most recently published reports:
Current published reports:
- MSCB Child H1 SCR (published December 2017)
- MSCB Child I1 SCR (published December 2017)
- MSCB Child K1 SCR (published December 2017)
- MSCB Child F1 SCR (published May 2018)
- MSCB Child G1 SCR (published May 2018)
- MSCB Child L1 SCR (published May 2018)
All media enquiries relating to the publication of SCRs should be made to the MSB Communications Manager on tele: 0161 234 3330 or email: email@example.com
MSCB SCR Learning Packs – resources for practitioners
Supporting learning events, which are planned to take place on a monthly basis, will be advertised on the MSB Training website.
Child E1 SCR: Learning event held April 2018; report not published
- MSCB Child E1 SCR Learning Report (published May 2018)
- MSCB Child E1 SCR Learning Presentation (published May 2018)
- MSB Child E1 SCR 7MB (published May 2018)
Child F1 SCR: Learning event held April 2018; full report published 15.05.2018
- MSCB Child F1 SCR Learning Report (published May 2018)
- MSCB Child F1 SCR Learning Presentation (published May 2018)
- MSB Child F1 SCR 7MB (published May 2018)
Child G1 SCR: Learning event held September 2017; full report published 15.05.2018
- MSCB Child G1 SCR Learning Report (published May 2018)
- MSCB Child G1 SCR Learning Presentation (published May 2018)
- MSB Child G1 SCR 7MB (published May 2018)
Child H1 SCR: Learning event held October 2017; full report published 14.12.2017
- MSCB Child H1 SCR Learning Report (published September 2017)
- MSCB Child H1 SCR Learning Presentation (published September 2017)
- MSB Child H1 SCR 7MB (published September 2017)
Child I1 SCR: Learning event held November 2017; full report published 14.12.2017
- MSCB Child I1 SCR Learning Report (published November 2017)
- MSCB Child I1 SCR Learning Presentation (published November 2017)
- MSB Child I1 SCR 7MB (published November 2017)
Child J1 SCR: Learning event held December 2017; report not published
- MSCB Child J1 SCR Learning Report (published December 2017)
- MSCB Child J1 SCR Learning Presentation (published December 2017)
- MSB Child J1 SCR 7MB (published December 2017)
Child K1 SCR: Learning event May 2018; full report published 14.12.2017
- MSCB Child K1 SCR Learning Report (published December 2017)
- MSCB Child K1 SCR Learning Presentation (published December 2017)
- MSB Child K1 SCR 7MB (published December 2017)
Child L1 SCR: Learning event held May 2018; full report published 15.05.2018
- MSCB Child L1 SCR Learning Report (published May 2018)
- MSCB Child L1 SCR Learning Presentation (published May 2018)
- MSB Child L1 SCR 7MB (published May 2018)
Child M1 SCR: Learning event to be held October 2018; full report published 20.08.2018
Child N1 SCR: Learning event held September 2018; full report to be published late 2018
- MSCB Child N1 SCR Learning Report (published Sept 2018)
- MSCB Child N1 SCR Learning Presentation (published Sept 2018)
- MSB Child N1 SCR 7MB (published Sept 2018)
Child O1 SCR: Learning event to be held November 2018; full report to be published late 2018
National Learning from SCRs
The NSPCC produces a useful series of briefing papers containing findings from Serious Case Reviews against various themes – these can be found on thier website www.nspcc.org.uk
National Panel of Independent Experts on Serious Case Reviews
The National Panel of Independent Experts was established to support LSCBs to make sure that appropriate action is taken to learn from serious cases and to ensure that lessons learned are shared through publication of the final report.
The Panel published its second annual report 10 November 2015 in which it comments on decision making by Safeguarding Boards and the quality of published Serious Case Reviews – find these reports on the website www.gov.uk
National Findings from Serious Case Reviews
Ofsted no longer evaluate Serious Case Reviews as set out in Working Together to Safeguard Children 2015, in line with recommendations from the Munro Review – read more on the website www.workingtogetheronline.co.uk
Ofsted have previously published reports summarising lessons learnt from SCRs:
- Learning Lessons from Serious Case Reviews 2009 – 2010 analysis of 147 serious case reviews completed between 1 April 2009 and 31 March 2010.
- Ages of concern: learning lessons from serious case reviews published October 2011 provides a thematic analysis of 482 serious case reviews evaluated between 1 April 2007 and 31 March 2011.
NSPCC National Case Reviews Repository
The repository provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level.
The repository is accessible via the NSPCC library online, which has over 800 case reviews and inquiry reports dating back to 1945.
The NSPCC website has further information about the Repository, research on case reviews and a list of all learning from case review briefings.
- Sign up direct for alerts from the NSPCC website
- Obtain a list of reports held in the Repository for a LSCB or topic:
- Open the NSPCC library catalogue
- Under Advanced search
- Select Publisher from the Search in drop-down menu
- Enter the relevant name in the Search terms box e.g. Manchester
- Select Case reviews from the Media type drop-down menu.
Legislation and guidance
SCRs are conducted under the guidance of Working Together To Safeguard Children 2015 (Chapter 4).
Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the function of LSCBs.
The Association of Independent LSCB Chairs website publishes a number of useful document and links; these include advice relating to the publication of anonymised SCRs.
MSCB SCR resources for reviewers and practitioners involved in the SCR process
The Information sheet on Practitioner Learning Events (June 2017) can be given to practitioners asked to attend a learning event.
MSCB SCR resources for families
Information for families about the SCR process can be found on the MSCB SCR Family Information sheet (Aug 2017)
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