Skip to content
You are here: Home | Children and young people | For professionals | Local child safeguarding practice reviews

Local child safeguarding practice reviews

Important lessons can be learnt from the detailed review of cases where children have died or received a life-threatening injury due to abuse or neglect. Swindon Safeguarding Partnership will undertake reviews of these and other serious child abuse cases in accordance with the national guidance set out in Working Together to Safeguard Children 2018.

Guidance on Child Safeguarding Practice Reviews and the responsibilities of the Safeguarding Partners is set out in working together 2018.

A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR) is undertaken when a child dies or the child has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children.

The trigger for this is a notifiable incident –

There is a Duty on local authorities to notify incidents to the Child Safeguarding Practice Review Panel (this is a National Panel). Working Together 2018 states that  a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if

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

Initially a rapid review will be undertaken in order to ascertain whether a local child safeguarding practice review is appropriate , or whether the case may raise issues which are complex or of national importance such that a national review may be appropriate.

The Swindon Safeguarding Partnership has a sub-committee which oversees and quality assures all the child safeguarding practice reviews undertaken by the Board, and provides advice on whether the criteria for conducting a review have been met. 

Upon completion of a child safeguarding practice review, there is an expectation that the final report is published in full and will be available on the website for a minimum of 12 months. The report will include

  • a summary of any recommended improvements to be made by persons in the area to safeguard and promote the welfare of children
  • an analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report.

Any recommendations will be clear on what is required of relevant agencies and others collectively and individually, and by when , and focussed on improving outcomes for children. Additional information and guidance in relation to child safeguarding practice reviews can be found in the statutory guidance Working Together to Safeguard Children 2018.

In addition to child safeguarding practice reviews, the Safeguarding Children Partnership will also undertake Multi-Agency Case Reviews / Partnership Reviews which do not meet the criteria for a child safeguarding practice review, but are considered to offer good opportunities to identify lessons for learning and ways in which multi-agency practice to safeguard children and young people can be improved locally.

Local Child Safeguarding Practice Reviews

The Swindon Safeguarding Partnership (SSP) commissioned a thematic review of three rapid reviews that had been conducted all involving babies under one who have suffered non-accidential injuires. Published 26th January 2022.

The key areas of learning from this review have already been disseminated through partner agencies and an action plan for ensuring that the learning is embedded will be monitored by the Safeguarding Partnership.

Learning from case reviews

Local case review - Child Y - January 2020

A local case review was commissioned by Swindon Safeguarding Partnership into the case of a 19-year-old female referred to as Y. The key areas of learning themes are detailed in a practice brief document.  

The key areas of learning from this review have already been disseminated through partner agencies and an action plan for ensuring that the learning is embedded will be monitored by the Safeguarding Partnership.

Serious case review - Child G - January 2020

The Swindon Safeguarding Partnership published the report on 16 January 2020 arising from a serious case review in relation to the the sudden and unexplained death of a ten-week-old baby.

Serious case review - Child Q - Nov 2019

The Swindon Safeguarding Partnership published the report on 27 November 2019 arising from a serious case review in relation to the severe neglect of a child. 

Serious case review - Child U - July 2019

The Swindon Safeguarding Partnership published the report on 29 July 2019 arising from a serious case review following the sudden and unexpected death of a one year old child.

Serious case review - Child D and Child S - 2016

In late 2016 Swindon LSCB published two serious case reviews following the deaths of two babies as a result of co-sleeping. The cases are not connected and occurred six months apart.

Serious case review reports are made available as PDFs on these pages for 12 months after the date of publication. After this time, you can apply to the Safeguarding Partnership Business Team if you wish to access an archived executive summary by contacting us at email: safeguardingpartnership@swindon.gov.uk

National repository of published case reviews

The national repository of published case reviews is a collaboration between the NSPCC and the Association of Independent LSCB Chairs. The aim is to hold all case reviews in a central location, so the learning contained within them is easier to access.

About the repository

Case reviews provide valuable lessons about how organisations are working together to safeguard and promote the welfare of children. However, despite organisational efforts to learn from serious cases, there is longstanding concern that the same issues are being identified again and again.

The NSPCC’s information service will continue to catalogue the published case reviews, including a summary and keywords. This allows reports to be retrieved by theme, for example, domestic abuse and parental mental health issues. The catalogue record will include either a link to the Swindon Safeguarding Partnership website, or a link to an electronic version stored within the library catalogue.

In addition, the NSPCC’s information service is developing a series of at-a-glance case review learning analyses focussed on recurring themes, such as parental substance misuse and domestic abuse. These analyses are intended as brief summaries of key learning written for practitioners presented in an easily digestible format. To find out more, see the NSPCC website.

Swindon Safeguarding Partnership learning and improvement framework

We are required under Working Together 2018 to maintain a Local Learning and Improvement Framework which is shared across local organisations who work with children and families. This framework sets out the type of case reviews and audits that the partnership undertakes and collates learning from those reviews. 

Swindon Safeguarding Partnership has developed a Learning & Improvement Framework to enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result. This adheres to the principles established in Working Together 2018 and is designed to underpin and facilitate the development of a culture of continuous improvement across children's safeguarding in Swindon.