Local Child Safeguarding Practice Reviews and Case Learning leaflets
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 2023.
Guidance on Child Safeguarding Practice Reviews and the responsibilities of the Safeguarding Partners is set out in working together to safeguard children 2023.
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 2023 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 oversees and quality assures all the Child Safeguarding Practice Reviews undertaken 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 2023.
Swindon Safeguarding Partnership has developed local guidance for undertaking reviews, which can be found here:
Whenever the Swindon Safeguarding Partnership carries out a case review, one of its main aims is to identify learning and share it with agencies and practitioners to support the development of services and practice.
These leaflets summarise the learning from reviews and all contain links to further information and training opportunities.
Swindon Safeguarding Partnership Case Reviews
June 2024 - Local Child Safeguarding Practice Review - Tristan
A Local Child Safeguarding Practice Review has been undertaken around, low school attendance, adolescent neglect and mental health. This was published on 24 June 2024.
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.
March 2023 - Local Child Safeguarding Practice Review - Alan
A Local Child Safeguarding Practice Review has been undertaken around adolescent neglect and was published on 20 March 2023.
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.
- Alan full report
- Alan practice learning brief (sets out the learning for agencies and practitioners that has been identified in this case review)
December 2022 - Local Child Safeguarding Practice Review - Bella and Ben
A Local Child Safeguarding Practice Review has been undertaken around the neglect of two young children and was published on 12 December 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.
- Bella and Ben full report
- Bella and Ben executive summary
- Bella and Ben practice learning brief (sets out the learning for agencies and practitioners that has been identified in this case review)
January 2022 - Local Child Safeguarding Practice Review - Babies with Injuries
The Swindon Safeguarding Partnership commissioned a thematic review of three rapid reviews that had been conducted all involving babies under one who have suffered non-accidental injuires. Published 26 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.
January 2020 - Local case review - Child Y
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.
November 2019 - 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.
- SCR Q - Full report (PDF)
- Learning leaflet - SCR Q (PDF)
September 2019 - Serious case review - Child M
A serious case review was published by Oxfordshire Safeguarding Children’s board in 2019, relating to Child M who moved from Swindon to the Oxfordshire area and was subsequently killed by his mother.
Despite its tragic outcome, this was a case where the main agencies with responsibility to work with children were rightly focused on the needs of the child. The SCR identified strengths in professional practice and service provision which would contribute to good outcomes for children in other cases. The review also identified learning which is set out in this leaflet.
August 2019 - Serious case review - Child G
Pregnancy and the first year of life is a critical life stage – in the first 18 months of life babies experience a period of incredibly rapid growth and development.
Research and experience indicate that very young babies are extremely vulnerable and premature babies may be more vulnerable to abuse and neglect. This may be increased if families are experiencing problems, and/or have premature twins/multiple births. (NSPCC 2017)
This learning leaflet sets out some of the learning for agencies and practitioners that has been identified through recent case reviews.
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.
