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Bradford Safeguarding Children Board > Serious Case Reviews (SCR)

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Acting on recommendations contained within Lord Laming's 2009 report: "Protection of Children in England, a progress report", the National Safeguarding Delivery Unit and the Department for Children, Schools and Families are revising the statutory guidance "Working Together to Safeguard Children".

Lord Laming recommended that the highest priority be given to revising Chapter 8 of Working Together, which sets out statutory arrangements for undertaking Serious Case Reviews. The revised Chapter 8 was published in December 2009, and had immediate effect.  The updated version can be seen here:

Working Together 2013 - Chapter 4: Learning & Improvement

To enable practitioners and policy makers to learn the key lessons from all serious case reviews undertaken in England, the Department for Children Schools and Families publishes biennial studies. The most recent of these can be downloaded below. 

Shorter briefings drawing out the key lessons from each of these documents have also been prepared by Bradford Safeguarding Children Board, and they can be downloaded too:

Title Full Briefing/Summary
"Ages of Concern - Learning Lessons from Serious Case Reviews" - A thematic report of Ofstedís evaluation of serious case reviews from 1 April 2007 to 31 March 2011
 
Download Download
"Improving Safeguarding Practice: Study of Serious Case Reviews 2001-2003"
 
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"Analysing Child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-05"
 
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"Understanding Serious Case Reviews and their Impact: a biennial analysis of serious case reviews 2005-07"
 
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"Learning Lessons from Serious Case Reviews 2009/10"
 
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"The Voice of the Child: Learning Lessons from Serious Case Reviews". This report is based on Ofsted's evaluation of Serious Case Reviews undertaken between 1st April - 30th September 2010
 
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Serious Case Review Newsletter #1 - April 2011
 
Download N/A
Serious Case Review Newsletter #2 - January 2012
 
Download N/A

Below are serious case review templates which can be used for information and training purposes. 

Title Word Version
IMR Guidance Notes 2011 Download
IMR Template 2011 Download

When must BSCB consider conducting a serious case review?
Local Safeguarding Children Boards are required to consider holding a serious case review when a child dies and abuse or neglect is known or suspected to be a factor in the death. In addition, Local Safeguarding Children Boards should always consider whether a serious case review should be conducted where:

  • a child sustains a potentially life-threatening injury or serious and permanent impairment of health and development through abuse or neglect; or

  • a child has been subjected to particularly serious sexual abuse; or

  • a parent has been murdered and a homicide review is being initiated; or

  • a child has been killed by a parent with a mental illness; or

  • the case gives rise to concerns about inter-agency working to protect children from harm.

What is the purpose of a serious case review?
The purpose of a serious case review is to:

  • establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguarding and promote the welfare of children;

  • identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; and

  • as a consequence, improve inter-agency working and better safeguard and promote the welfare of children.

Serious case reviews are not inquiries into how a child died, or who is culpable. that is a matter for Coroners and criminal courts, to determine as appropriate.

Where can I find guidance about serious case reviews?
Chapter 4 of Working Together to Safeguard Children 2013 contains detailed guidance regarding serious case reviews and the processes involved.

The Bradford Safeguarding Children Board Procedures for serious case reviews can be accessed here.

BSCB has a serious case review monitoring sub-group which ensures that procedures and arrangements for undertaking serious case reviews are in place and complied with, and also monitors the progress of agency action plans which are intended to ensure that the recommendations for serious case reviews are implemented.

How can agencies and individual staff learn the lessons of serious case reviews?
Bradford Safeguarding Children Board will normally publish an anonymised executive summary of each serious case review, unless to do so is prejudicial to civil or criminal processes. These executive summaries will appear on this website, below.

The government collates information from all serious case reviews undertaken within England and Wales, and produces a report every two years which draws out the main themes and lessons from the reviews.

Improving safeguarding practice - Study of serious case reviews 2001-2003

Analysing child deaths and serious injury through abuse and neglect: what can we learn?
A biennial analysis of serious case reviews 2003-2005


For information on training around Serious Case Reviews please click here.


North Somerset LSCB Serious Case Review into abuse in a first school.

This SCR was conducted after the arrest of a teacher suspected of abusing children in his care. Many of you will be familiar with the case which received significant media coverage.

When publishing the SCR Overview Report and Executive Summary in late January 2012, the North Somerset LSCB Chair recommended that the SCR 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, Tim Loughton MP, has asked, exceptionally in this case, for this SCR completed by North Somerset LSCB to be brought to the attention of all LSCBs to consider the implications for schools in their areas. The links to both the Overview Report and Executive Summary are provided below.

http://www.northsomersetlscb.org.uk/uploads/files/283.pdf

http://www.northsomersetlscb.org.uk/uploads/files/282.pdf


BRADFORD SERIOUS CASE REVIEW EXECUTIVE SUMMARIES

Each serious case review executive summary published by Bradford Safeguarding Children Board since 2008 is available for download below:

Diljeet - Serious Case Review

On March 22nd 2016, Bradford Safeguarding Children Board (BSCB) published the overview report of a serious case review (SCR) that is commissioned following the tragic death of Diljeet (not real name). Diljeet died on 18th February 2014 as a result of significant injuries experienced whilst in the care of her mother. This case has been the subject of both a criminal trial and a coronerís inquest.

The SCR considered the services provided to Diljeet and her family in both Hertfordshire, where she and her mother previously resided, and Bradford. The overview report identifies lessons to be learned from the case, considers the actions already taken by agencies as a result of the case and makes further recommendations for service improvements. Hertfordshire and Bradford Local Safeguarding Children Boards will monitor the progress of the services in their respective areas against the recommendations made.

Regarding this case, David Niven, Independent Chair of Bradford Safeguarding Children Board, said: "This was a tragic incident. A serious case review - an independent investigation - has been held to look at the care Diljeet (not her real name) and her mother received in Hertfordshire and in Bradford."

"The review found that Diljeet's death was not predictable. It found that whilst in Bradford Diljeet's mother was well supported and given opportunities to access additional support. We are always looking to improve the services we provide to cater for people's individual cultural needs. Reports like this focus our attention on how we can achieve this."

"Whilst this review has been in process agencies involved have learnt lessons and taken action in order to improve the services they provide."

Click here for a PDF copy of the SCR


Hamzah Khan Serious Case Review Executive Summary (published 13 November 2013)
Bradford Safeguarding Children Board commissioned a Serious Case Review after becoming aware of the death of Hamzah Khan in September 2011. This review was published on 13 November 2013.

Other documents relating to this SCR can be found here


Child J - Serious Case Review Executive Summary (published March 7th 2011)
On Monday 7th March 2011, Bradford Safeguarding Children Board published the Executive Summary of the Serious Case review concerning Child J, who died of multiple stab wounds on 18th February 2010 following an attack by his older brother.

Professor Nick Frost, Independent Chair of Bradford Safeguarding Children Board, said: "Our thoughts are with Child Jís family who have suffered the terrible loss of a child in such tragic circumstances.

"While the independent serious case review concludes that Child Jís death could not have been anticipated, it has outlined a number of lessons that we can all learn regarding the care and support Child J and his family received from a range of agencies during his life.

"A great deal of attention was focussed on Child Jís older brother and sometimes on other children in the family without enough regard being given to the family as a whole and the impact their behaviour had on each other.

ďAll agencies involved have already taken steps to improve the way they share information and to look at how they can better work together to help families dealing with mental health and other issues." - Download PDF version here.


Child D - Serious Case Review Executive Summary (published February 7th 2011)
On February 7th 2011, Bradford Safeguarding Child Board published the executive summary of the Serious Case Review undertaken into the death of Child D.

Professor Nick Frost, Independent Chair of Bradford Safeguarding Children's Board, said: "Our thoughts are with the family who are still dealing with the death of a loved one in harrowing circumstances.

"An independent investigation known as a Serious Case Review has been held to look at the care and support Child D and his family received from a range of agencies during his life.

"The Serious Case Review (SCR) has outlined a number of lessons we can all learn regarding the quality of care he received. The SCR concludes that while agencies focused on Child D and his needs, they should have looked more closely at how his health and disability affected his family.

"While the care and support Child D received was unconnected to his death, we all need to learn from the points raised by the SCR to continue to raise our standards of practice. All agencies involved have already taken steps to improve the services they provide to children with disabilities and complex health needs, and are committed to working together to ensure the safety of children across the district." - Download PDF version here.


AI
This report provides a summary of the findings of the serious case review undertaken on behalf of Bradford Safeguarding Children Board following a serious injury to AI, aged 5 months, on 27th February 2007. It reproduces in full the recommendations of the review for Bradford Safeguarding Children Board and its member agencies.  Action plans to ensure completion of the recommendations were produced and subsequently monitored on behalf of BSCB and all action plans have now been completed.  This SCR was evaluated by Ofsted as adequate.- download PDF version here.


HD
This report provides a summary of the findings of the serious case review undertaken on behalf of Bradford Safeguarding Children Board following the death of HD, aged 2 years, on 16th July 2006. It reproduces in full the recommendations of the review for Bradford Safeguarding Children Board and its member agencies. - download PDF version here