A boy's hand thrust forward towards the camera

Learning and development


Child Safeguarding Practice Reviews (SPRs) (formerly Serious Case Reviews) in England 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, Local Safeguarding Children Partnerships (formerly LSCBs) may decide to conduct an SPR whenever a child has been seriously harmed and in accordance with the guidance in Working Together 2023. Further information regarding child deaths is available on the CYSCP child deaths page.

Serious child safeguarding cases are those in which:

  • abuse or neglect of a child is known or suspected, and
  • the child has died or been seriously harmed

Purpose of a Safeguarding Practice Review

The prime purpose of an SPR 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.

Since 2013 there has been a National Panel of Independent Experts to advise LSCBs and Partnerships about the initiation and publication of SCRs. The panel’s remit includes advising LSCBs and Partnerships about:

  • application of the SPR criteria
  • appointment of reviewers
  • publication of SPR reports
  • commissioning of national SPRs where there is learning which would be of value nationally

What the Child Safeguarding Practice Review Panel does

In 2018 a new National Panel for Child Safeguarding Practice Review Panel was set up by the Department for Education. This is an independent panel which can commission reviews of serious child safeguarding cases where they are complex and /or in the national interest.

The Child Safeguarding Practice Review Panel is an independent panel commissioning reviews of serious child safeguarding cases. They require national and local reviews to focus on improving learning, professional practice and outcomes for children.

Top of page


Thematic reviews are carried out nationally by the Child Safeguarding Practice Review Panel. They are an independent panel who commission reviews of serious child safeguarding cases. They require national and local reviews to focus on improving learning, professional practice and outcomes for children.

The Child Safeguarding Practice Review Panel works with the Department for Education. They are an independent panel commissioning reviews of serious child safeguarding cases. They aim to ensure that national and local reviews focus on improving learning, professional practice and outcomes for children.

Recent reviews, research and analysis carried out by the Panel include:

  • Safeguarding children with disabilities in residential settings review
  • Management of bruising in non-mobile infants paper
  • Multi-agency safeguarding and domestic abuse paper
  • National Review into the murders of Arthur Labinjo-Hughes and Star Hobson

The safeguarding children with disabilities in residential settings review (GOV.UK) sets out recommendations and findings for national government and local safeguarding partners to protect children at risk of serious harm.

The phase 1 report examines allegations of abuse and neglect to children living in three private residential settings located in Doncaster and operated by the Hesley Group:

  • Fullerton House
  • Wilsic Hall
  • Wheatley House

The phase 2 report sets out recommendations to improve the safety, support and outcomes for children with disabilities and complex health needs living in residential settings.

The management of bruising in non-mobile infants paper (GOV.UK) from the Child Safeguarding Practice Review Panel is part of an ongoing series of publications to share information arising from work undertaken by the panel with:

  • safeguarding partners
  • those working in child protection

This paper explores the current guidance on the management of bruising in non‑mobile infants in the light of published evidence and variations in practice.

The aim of this paper is to support safeguarding partners in reviewing their current policies on bruising in non-mobile infants and to make recommendations on how the evidence base and national guidelines can be further developed.

The multi-agency safeguarding and domestic abuse paper (GOV.UK) is part of an ongoing series of publications to share information arising from work undertaken by the panel with:

  • safeguarding partners
  • those working in child protection

This paper sets out key findings from a thematic analysis of rapid reviews and local child safeguarding practice reviews where domestic abuse featured.

It summarises the most common themes that emerged in relation to multi‑agency safeguarding for children who are victims of domestic abuse and includes examples of practice and recommendations.

The National Review into the murders of Arthur Labinjo-Hughes and Star Hobson (GOV.UK) sets out recommendations and findings for national government and local safeguarding partners to protect children at risk of serious harm.

It examines the circumstances leading up to the deaths of Arthur Labinjo-Hughes and Star Hobson and considers whether their murders reflect wider national issues in child protection.

Child Safeguarding Practice Review Panel Annual Reports

The Child Safeguarding Practice Review Panel: Annual Report 2021 (GOV.UK) is the third annual report from the independent Child Safeguarding Practice Review Panel. It looks at the child safeguarding system, based on serious child safeguarding incidents occurring between 1 January and 31 December 2021. It sets out patterns in practice for national government and local safeguarding partners to better protect vulnerable children.

The Child Safeguarding Practice Review Panel: Annual Report 2020 (GOV.UK), an independent annual report for serious child safeguarding incidents in 2020, is the second annual report from the Child Safeguarding Practice Review Panel.

It looks at serious child safeguarding incidents between 1 January and 31 December 2020.

It sets out patterns in practice for national government and local safeguarding partners to better protect vulnerable children.

The Child Safeguarding Practice Review Panel: Annual Report 2018 to 2019 (GOV.UK) is the first annual report from the Child Safeguarding Practice Review Panel.

The National Child Mortality Database (NCMD) is an NHS funded programme, delivered by the University of Bristol, that gathers information on all children who die in England. They aim to learn lessons that could improve and save children’s lives in the future.

Further useful resources and information

Complexity and challenge: A triennial analysis of serious case reviews 2014-2017 analyses 368 Serious Case Reviews (SCRs) relating to incidents between 1 April 2014 and 31 March 2017. This is the sixth consecutive analysis of SCRs by this research team; together these reports cover 14 years from 2003-2017.

The Serious Case Reviews website contains the full report, as well as other useful reports. See Serious Case Reviews - Archived Resources.

The NSPCC have also been working with the Association of Independent LSCB Chairs to create the National Case Review Repository (NSPCC Learning) to make it easier to access and share learning at a local, regional and national level.

Top of page


Where cases have been shared with another authority, for instance if a child is place out of area with another authority, we will share the learning.

We will also publish and share learning within our regional network.

The regional local LSCP's are:

Top of page


We've produced the following 7 Point Briefings to disseminate learning from case reviews:

The following presentation and 7 point briefing is learning from practice identified at Hull SCP following a local learning lessons review. This case was discussed by the CYSCP and identified as useful learning for all professionals:

Top of page


The CYSCP hold Learning Masterclass events to disseminate learning from the Partnership to professionals and practitioners.

View a selection of presentations from previous events.

CYSCP Learning Masterclass - 30 November 2021

CYSCP Learning Masterclass - 17 June 2021

Top of page


See 7 Point Briefing: Poppy - Learning from Practice for further information about this case.

See multi-agency training for further information about our safeguarding training courses and e-learning.

Top of page


Joint Targeted Area Inspections (JTAIs) are joint inspections carried out by:

The inspectorates jointly assess how local authorities, police, health, probation and youth offending services are working together in an area to identify, support and protect vulnerable children and young people.

See the JTAI One Minute Guide for more information.

Top of page