Serious Case Reviews

Serious Case Reviews (SCRs) are undertaken when a child dies (including death by suspected suicide), and abuse or neglect is known or suspected to be a factor in the death. Additionally, LSCBs may decide to conduct a SCR whenever a child has been seriously harmed in the following situations:

  • a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and 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 under the Domestic Violence Act 2004;
  • a child has been seriously harmed following a violent assault perpetrated by another child or an adult;

and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. This includes inter-agency and inter-disciplinary working.

The prime purpose of a SCR is for agencies and individuals to learn lessons to improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children.

Local Safeguarding Children Boards (LSCBs) are required, under Chapter 4 of the statutory guidance, Working Together to Safeguard Children 2015 to undertake a Serious Case Review when a child has died or been seriously harmed as a result of abuse or neglect and where there there is cause for concern about the way agencies have worked together to safeguard children.

Since 2013 there has been a national panel of independent experts to advise LSCBs about the initiation and publication of SCRs. The panel’s remit includes advising LSCBs about:

• application of the SCR criteria;

• appointment of reviewers; and

• publication of SCR reports.

Until May 2010, LSCBs were required to publish an Executive Summary of the Serious Case Review overview reports. However, since that date, LSCBs are now required to publish overview reports in full.

Child A, B and C (published 31/01/11)

Child B (published 10/10/13) For legal reasons only a brief summary of the case along with the lessons can be published

Baby A (published 11/10/13) For legal reasons some of the content of the Executive Summary have been redacted

Thematic review of child neglect (published 24/1/13) - A 2 year study of the professional responses to child neglect within York

Messages from reviews (Published 2014) - A review of all case reviews undertaken by the CYSCB since 2007