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Rapid reviews and serious case 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.

Learning from serious case reviews

Learning leaflets for all serious case reviews can be found on the training statement page.

Serious case review - child G

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.

The key areas of learning from the serious case 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.

The report can be viewed and downloaded below:

Serious case review - child Q

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. 

The key areas of learning from the serious case 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.

The report can be viewed and downloaded below:

Serious case review - child U

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.

The key areas of learning from the serious case 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.

The report can be viewed and downloaded below:

Serious case review - child D and child S

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 6 months apart.

Both reviews confirmed that all professionals had provided clear safe sleeping advice to the families. However, both families were within the child protection system and it was felt that there would be learning for organisations.

The reports can be viewed and downloaded below:

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.

All reports are important, but some have reached a high level of national significance due to the severity of the cases. These reports contain learning that extends beyond the areas where the tragic events took place and it is important the all LSCBs, agencies and practitioners are aware of them.

The thematic review, published in July 2015, was considered by the Swindon LSCB Case Review Sub Group in September 2015. This briefing is based on case reviews published since 2013, where the mental health problems of parents were a key factor. It pulls together and highlights the learning contained in the published reports.

When publishing the serious case review overview report and executive summary, the LSCB Chair recommended that the serious case review was read by every head teacher, every chair of governors and safeguarding boards across the country because of the issues it raises and the recommendations it makes. The Parliamentary Under Secretary of State for Children and Families asked for the serious case review to be brought to the attention of all LSCBs and DCSs to consider the implications for schools in their areas.

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.