Safeguarding Practice Reviews (formerly Serious Case Reviews)

This page is currently under review.

Child Safeguarding Practice Reviews (SPRs) (formerly Serious Case Reviews (SCRs)) 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 2018:

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

The criteria which the local safeguarding partners must take into account include whether the case:

  • highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified
  • highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children
  • highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children
  • is one which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate

Safeguarding partners should also have regard to the following circumstances

  • where the safeguarding partners have cause for concern about the actions of a single agency
  • where there has been no agency involvement and this gives the safeguarding partners cause for concern
  • where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around
  • where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings

Some cases may not meet the definition of a ‘serious child safeguarding case’, but nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near miss’ events. Safeguarding partners may choose to undertake a local child safeguarding practice review in these or other circumstances.

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 national

Useful Links

Check the NSPCC National Case Review Repository of Serious Case Reviews and Safeguarding Practice Reviews

7 Point Briefing - Learning from Practice - Multi Agency Learning 

Local Cases - City of York Safeguarding Children Partnership (CYSCP)

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 CYSCP since 2007