View Working Together View Working Together

10.2 A Toolkit for Conducting Serious Case Reviews (Guidance, Templates and Alternative Learning Methods)

This chapter deals with Serious Case Reviews and the learning process that should emerge from them and reflects policy, process, regulation and guidance on criteria for each. Methods for conducting Serous Case Reviews and other evaluations of concern are highlighted. The emphasis on ‘putting the child at the centre’ and of appropriate learning is at the heart of this chapter.


Investigation of Sudden Unexpected Deaths in Childhood Procedure

Reviewing All Childhood Deaths Procedure

Serious Case Review Procedure


Working Together to Safeguard Children

The Local Safeguarding Children’s Board Regulations 2006


This chapter was updated in March 2019 to reflect the introduction of the General Data Protection Regulations (GDPR) and the updated Data Protection Act 2018 (see Section 4.11, Role and Functions of the Serious Case Review Panel).


  1. Introduction
  2. Statutory Guidance - Working Together to Safeguard Children
  3. General Principles for Learning and Improvement
  4. Serious Case Reviews
  5. Individual Agency Reports
  6. The Systems Approach
  7. Parallel Processes
  8. Media Strategy
  9. Learning from Serious Case and other Reviews
  10. Action Following Completion of the Review

    Appendix 1: Guidance for Agency Reports

    Appendix 2: Significant Incident Notification Form

    Appendix 3: Incident Notification Form

1. Introduction

All agencies represented on the Lincolnshire Safeguarding Children's Board (LSCB) are committed to ensuring that any necessary Serious Case Review/Learning Event will be undertaken thoroughly, promptly and sensitively. In addition, the Board is determined that lessons learned will be acted upon swiftly to address any shortcomings in practice, policies or procedures.

This guidance should assist participants and those affected by the process to understand their role and responsibilities; be able to contribute positively and act on findings. It aims to support an effective Serious Case Review/Learning Event through a consistent approach and by providing additional guidance on how to undertake the process by sharing lessons and good practice tools and exemplars. It should be read alongside the statutory guidance in Chapter 4 of Working Together to Safeguard Children.

2. Statutory Guidance - Working Together to Safeguard Children

Working Together to Safeguard Children states that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children. These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved in local cases but wider to promote understanding of what works well and also why things can go wrong.

This Lincolnshire Serious Case Review (SCR) toolkit supports the work of the Safeguarding Board and partners so that:

  • Reviews are conducted regularly, not only on cases that meet the statutory criteria, but also on other cases that can provide useful insights into the ways that organisations are working together to safeguard and protect the welfare of children;
  • Reviews look at what happened in a case, and why and what action will be taken to learn from the review findings;
  • Actions result in lasting improvements to services;
  • There is transparency about issues from individual cases and the actions taken in response to them. This includes sharing final SCR reports with the public.

The Learning & Improvement Framework includes a full range of reviews and audits aimed at driving improvements to safeguard and promote the welfare of children. Some of these reviews, (i.e. SCRs and child death reviews), are required under legislation and their conduct is determined by set criteria. It is important that LSCB understands the criteria for determining whether a statutory review is required and always conduct those reviews when necessary.

LSCB's should also conduct reviews of cases which do not meet the criteria for an SCR, but which can provided valuable lessons about how organisations are working together to safeguard and promote the welfare of children. Although not required by statute these reviews are important for highlighting good practice as well as identifying improvements which need to be made to local services. Such reviews many be conducted by a single organisation or by a number of organisations working together. LSCB's should follow the principles in Working Together to Safeguard Children when conducting these reviews.

Types of Review

Review types include:

  • Serious Case Reviews for every case where abuse or neglect is known or suspected and either:
    • A child dies; or
    • A child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.
  • Child death review - a review of all child deaths up to age 18;
  • Review of a child protection incident that falls below the threshold for an SCR;
  • Review or audit of practice in one or more agencies.

3. General Principles for Learning and Improvement

The following principles from 'Working Together to Safeguard Children' should be applied by to all reviews:

  • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice;
  • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
  • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
  • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process;
  • Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections. (It is necessary for some elements of reports to be redacted in order to protect the identity and safeguard family members, including other children);
  • Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children.

SCRs and other case reviews should be conducted in a way which:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
  • Is transparent about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

The following should be regarded as guiding principles in undertaking an SCR or other form of Learning Event:

  • Timely - Agencies must respond to a decision to undertake an SCR/Learning Event with appropriate urgency and should aim to conclude an SCR review within statutory timescales, i.e. six months from the date of the decision to proceed. The LSCB will only agree to an extension for a valid purpose e.g. to interview family members and secure their input. In such circumstances the Board Chair will inform the National Panel of Independent Experts of the new completion date and the reason for the extension;
  • Impartiality -The LSCB is independent of any of its partner agencies and the Review must be conducted fairly and impartially. Anyone who has had direct involvement with the child or their family should not be responsible for drafting reports;
  • Thoroughness - It is essential that the case is considered fully and all staff with relevant information have the opportunity to contribute;
  • Openness -The LSCB should be open with the family, and others affected by the Review regarding the process and outcomes. The final Report will be published at the conclusion of the Review and appropriate feedback given to those involved;
  • Confidentiality – All information gathered throughout the Review process must be treated as highly confidential and only shared or disclosed when appropriate;
  • Cooperation – The LSCB provides a framework to ensure close collaboration between all organisations and agencies involved in Reviews. The cooperation of all member organisations and agencies is essential in this process;
  • Resolution - At the conclusion of the Review an Action Plan must be produced incorporating the actions that each individual Agency has identified as necessary to ensure that lessons are learnt.

The LSCB and the Serious Incident Review Group (SIRG) should oversee implementation of actions and learning resulting from any type of Review and reflect on progress in its Annual Report.

3.1 Case Review methodologies

Statutory Reviews

Working Together to Safeguard Children gives authorities more flexibility about the methodology they choose to conduct an SCR - " LSCBs may use any learning model which is consistent with the above principles".

There are a number of case review methodologies which can be used as the basis for undertaking an SCR, and the list of alternative methodologies set out below is not exhaustive. Where the criteria for an SCR are met, a proposed process is set out in this Framework but the methodology to be used will be determined on a case by case basis, provided the methodology is consistent with the principles in 'Working Together to Safeguard Children'. Examples of some methodologies which can be utilised for conducting other types of Review/Learning Event are:

See also Section 6, The Systems Approach.

Non - Statutory Reviews

When conducting reviews on cases which do not meet the statutory SCR criteria or when conducting good practice reviews LSCB's are free to decide how best to conduct such reviews. Please complete and submit an incident monitoring form if you or your agency would like the LSCB to consider the review of an incident that does not meet the SCR criteria. See Appendix 2: Significant Incident Notification Form.

4. Serious Case Reviews

4.1 Purpose

The purpose of a Review/ SCR is to:

  • Identify improvements which are needed and to consolidate good practice;
  • Translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.

SCRs are not inquiries into how a child died or was seriously harmed, or into who is culpable. These matters are for Coroners and criminal courts to determine.

4.2 Criteria for Conducting a Serious Case Review

The criteria are set out in Chapter 4 of Working Together to Safeguard Children and additional guidance on the application of the criteria is provided in the DfE guidance National Panel of independent experts on Serious Case Reviews.

Regulation 5 of the LSCB Regulations 2006 sets out the Board's functions which include the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.

Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:

5. (1) The functions of an LSCB in relation to its objective (as defined in section 14(1) of the Act(1)) are as follows—
    (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.
  (2) For the purposes of paragraph (1) (e) a serious case is one where:
    (a) abuse or neglect of a child is known or suspected; and
    (b) either —
      (i) the child has died (includes by suicide); or
      (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

Cases which meet one of these criteria above must always trigger an SCR.

Where a case is being considered under regulation 5(2)(b)(ii), unless it is clear that there are no concerns about inter-agency working, the LSCB must commission an SCR.

In addition, an SCR should always be carried out when a child dies:

  • In custody;
  • In police custody;
  • On remand or following sentencing, in a Young Offender Institution;
  • In a secure training centre or a secure children’s home;
  • Where the child was detained under the Mental Health Act 2005.

If an SCR is not required because the criteria in Regulation 5(2) are not met, the LSCB may still decide to commission a non-statutory SCR or some alternative form of case review.

4.3 Deciding whether to hold a Serious Case Review

All partner organisations and agencies of the Board are responsible for identifying cases of concern that may meet the SCR criteria and ensuring that such incidents are brought to the attention of the LSCB. Each agency should have arrangements to ensure that serious safeguarding incidents are identified and appropriate notification arrangements effected using the Serious Incident Notification Form (SINF). See Appendix 2: Significant Incident Notification Form.

The Business Manager will inform the LSCB Independent Chair and the Chair of sub-group that a notification has been made and will ensure cases requiring consideration are placed on the agenda of the subsequent sub-group meeting. The case should be subject to a decision within one month of notification of the incident.

The Preliminary meeting of the Standing Serious Case Review Panel

Once it is apparent that an SCR may be needed, a preliminary meeting of the SCR Panel will be convened. The Business Manager will inform all LSCB members as follows:

  • Details of the case and known family members;
  • A request that all agency records involving the family should be secured as a matter of priority in accordance with the agency’s agreed processes;
  • An indication that information will need to be gathered for sharing at the preliminary Panel meeting;
  • Details of the arrangements for the preliminary Panel meeting if known at that stage.

The preliminary SCR Panel will share information about agency involvement in the case and determine whether to recommend to the LSCB Chair that the criteria for holding an SCR have been met. The Panel may also address whether other options should be considered and recommended e.g. an alternative type of learning event.

The preliminary Panel should comprise of representatives from all relevant services with legal advice as a minimum, as well as any other partner agency who has provided services to the child / family. Written and verbal information will be received at the Panel meeting. It is good practice for agencies to bring chronologies of their involvement with the family.

The discussion and decisions of the Panel meeting will be minuted. Decision making should be evidence based and explicit. Any disputes should be referred to the LSCB Chair who has ultimate responsibility for the decision.

If the Panel feels that important information is missing at this initial meeting it may defer a recommendation and adjourn until further information is available and all the facts established. Such delay is undesirable due to the potential impact on the statutory timetable for completing any SCR (six months from the date of the decision to proceed). All agencies should therefore ensure that they provide full and comprehensive information about their involvement with and knowledge of the family to the initial Panel meeting.

Following consideration of all the circumstances the Panel make a recommendation to the LSCB Chair as to whether the criteria have been met for conducting an SCR. Where the Panel determines that the criteria have been met, it will communicate this to the LSCB Chair and also put forward draft Terms of Reference for the Review

The final decision whether to initiate an SCR rests with the Chair of LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision and also at other stages in the SCR process.

The LSCB must let Ofsted and the National Panel of Independent Experts ( know their decision.

If the LSCB decides not to initiate an SCR, this decision may be subject to scrutiny by the national panel. The LSCB should provide information to the panel on request to inform its deliberations and the LSCB Chair should be prepared to attend in person to give evidence to the Panel.

If an SCR is not required because the criteria are not met, the Board may still decide to commission an SCR or choose to conduct an alternative form of case review.

4.5 Terms of Reference

The preliminary SCR Review Panel must agree comprehensive terms of reference to ensure they incorporate all the issues for a thorough review, to maximize learning and ensure production of a high quality and effective final Report. The LSCB Chair should ensure the terms of reference address all the key issues before approving them. Key considerations for determining the scope and terms of reference include:

  • The timescale for the detailed chronologies - how far back should they go?
    Families may have been known to agencies for many years so the review must be specific about the timeframe for the detailed chronology and any previous background information or early events relating to the family. A summary of agency involvement prior to recent years may be sufficient and allow the Review to concentrate on the detail of recent events;
  • Consideration of the views of the family and extended family
    The Review must decide which family members are to be included in the review, when they are to be interviewed and by whom. Reviews should decide who will contact family members, the timing and purpose of contact e.g. seeking views, seeking consent to share information, feeding back lessons, agreeing the final report. The final Report should clearly evidence how the family's views have influenced lessons learned from the Review;
  • Consideration of parallel processes
    The Review must consider the impact of other parallel processes such as care proceedings, criminal proceedings, inquests & other review processes to ensure that effective liaison and communication is in place to ensure the integrity of the SCR and other processes are not compromised;
  • Need for Expert advice
    The Review should address the possible need for expert opinion or advice at an early stage e.g. specific knowledge relating to any of the agency areas such as mental health or a particular cultural practice.

Although the terms of reference are determined at the outset once the SCR Review Panel has been established, they reserve the right to review and amend them if necessary in the light of new information as the Review progresses.

4.6 Preliminary SCR Panel Recommendations

The Business Manager will notify the LSCB Chair of the Panel’s recommendations. If the LSCB Chair agrees with the recommendation that the criteria for an SCR have been met, they must inform the Director of Children and Young People’s Services and the LSCB membership immediately of the decision to proceed with an SCR.

The Business Manager should also notify Ofsted and the National Panel of Independent experts about the decision to undertake an SCR.

Where the Panel determines that the criteria for holding a Serious Case Review have not been met, the LSCB Chair may consider the value of an alternative form of learning event if the Panel has not already suggested this. Responsibility for deciding whether or not to commission an SCR rests with the LSCB Chair. The Chair may decide upon other options irrespective of the Panel’s recommendation e.g. If it appears that there are lessons to be learned the Chair may decide that a single or multi-agency review should be undertaken outside of the SCR process. For concerns at a single agency level the LSCB may ask the agency to undertake an Agency Report for report back to the LSCB. In very rare cases an individual agency report may unearth additional information which indicates that the criteria for holding an SCR have, in fact, been met. In such circumstances the LSCB Chair should be notified to enable them to review their original decision and decide whether an SCR should be commissioned in the light of the new information.

4.7 Determining the Scope of a Serious Case Review

If it is agreed to recommend that the SCR criteria have been met, the preliminary Panel is also responsible for determining the scope of the SCR and terms of reference, but this may be subject to review once the full SCR review panel have considered the case. Relevant issues to be considered include:

  • What appear to be the most important issues to address in trying to learn from this specific case?
  • How can the relevant information best be obtained and analysed?
  • Are there features of the case that indicate that any part of the review process should involve, or be conducted by, a party independent of professionals or agencies who will be required to participate in the review?
  • Should the LSCB consider commissioning an outside expert at any stage, to highlight any crucial aspects of the case;
  • What time period should the Review cover i.e. how far back should enquiries commence and what is the cut-off point? What family history / background information will help better to understand the recent past and present?
  • Which family members and significant others should be included and at what point;
  • Which organisations, agencies and professionals should contribute to the review. They may be asked to submit reports or otherwise contribute;
  • How should family members contribute to the review, and who should be responsible for facilitating their involvement?
  • Will the case give rise to other parallel investigations of practice (independent health investigations or multi-disciplinary suicide review, a homicide review where a parent has been murdered, a Youth Justice Board Serious Incident Review and a Prisons and Probation Ombudsman investigation where the child/young person has died in a custodial setting). If so, how can a coordinated or jointly commissioned review process best address all the relevant questions that need to be asked?
  • Is there a need to involve organisations, agencies or professionals in other LSCB areas and what should be the respective roles and responsibilities for the various LSCBs?
  • How should the review process take account of a Coroner’s inquiry, and if relevant any criminal investigations or proceedings relating to the case? Who should liaise with the Coroner and /or the Crown Prosecution Service and how is this to be achieved;
  • Who will make the link with relevant agencies outside the main statutory remit e.g. the voluntary and community sector?
  • When should the Review process start, and by what date should it be completed? (This should be within 6 months unless an extension is required);
  • How should any public, family and media interest be managed before, during and after the review?

Some of these issues may need to be revisited as the Review progresses and new information emerges.

4.8 Children known to more than one Safeguarding Children Board

Where partner agencies of more than one LSCB have knowledge of, or contact with, a child, the LSCB for the area in which the child is (or was) normally resident should take lead responsibility for conducting and managing an SCR.

Any other Boards that have an interest or involvement in the case should co-operate as partners in jointly planning and undertaking the SCR. In the case of a Looked after Child the local authority looking after the child should exercise lead responsibility for conducting the SCR, again involving other LSCBs with an interest or involvement.

The lead LSCB should formally request any report required from agencies in another area through that area’s LSCB and formally notify the other LSCB of any recommendations made to agencies within its boundaries at the end of the review to facilitate the learning of local lessons.

4.9 Appointing Independent leads for the Serious Case Review

The LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. The lead reviewer should be independent of the LSCB and the organisations involved in the case. The LSCB should provide the National Panel of Independent Experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCB should consider carefully any advice from the independent expert panel about appointment of reviewers.

The SCR Panel Chair can be the independent LSCB Chair (as they are not from a member agency locally); the Chair of the Standing SCR sub - group or someone from an agency which is not involved in the case. The SCR Panel Chair should have relevant skills taking into account the specific issues in the case.

The primary role of the Chair and Panel is to ensure that the experience of the child is kept at the heart of the SCR. The review should ensure that a picture is built up of what life was like for the child and the involvement of agencies should be reviewed in light of this. This should be achieved throughout the agency reports and be reflected in the Final Report.

The SCR Panel Chair is responsible for:

  • Ensuring that the Panel operates effectively so that organisations and agencies collaborate to produce a comprehensive and thorough SCR in a timely fashion which identifies the lessons to be learned from the case and has established a framework to ensure they are learned;
  • Ensure that report authors are supported to meet agreed standards and requirements and timetable for submission;
  • Liaising with the LSCB chair and nominated senior manager to agree a revised timetable if the statutory timescale is unlikely to be met and ensure arrangements are made for notifying the DfE of any decision to extend the timescale;
  • Ensuring that agency reports are quality assured and any gaps and inconsistencies are identified so that necessary amendments can be made;
  • Investigating and attempting to resolve any disputes or issues of non-compliance by participating organisations or agencies;
  • Ensuring that the Final Report author has all the necessary information and acting as a point of contact for the author should questions or points of clarification arise;
  • Ensuring the draft final report is considered against the agreed Terms of Reference to ensure that they have been fulfilled;
  • Along with panel members, ensuring that the final report is comprehensive, well written and meets Working Together requirements.

The SCR Panel Chair and Business Manager should also ensure:

  • The appropriate professional expertise, level of experience and authority of the panel members;
  • The availability of expert advice to the Panel if needed;
  • Clarity of the purpose and the process to be applied throughout, so that everyone understands the task, their role in the process, and the expectations of the Panel - i.e. the agency report authors, Final Report author and senior staff in agencies;
  • Transparency – to ensure that objectivity and challenge is applied rigorously and consistently to all services throughout the process;
  • Equality of weight of the views of all SCR panel members – so that appropriate challenge and robust dialogue can take place;
  • Anonymity and confidentiality – to ensure that final reports are entirely and consistently anonymised with no loss of meaning, and that all information remains confidential;
  • Timeliness – ensure that progress is managed robustly throughout the process to meet statutory deadlines and agreed timescales;
  • Independence of the Final Report author from all agencies involved in the case, including the professionals and all SCR panel members;
  • Legal advice from the legal advisor to the LSCB is provided to the review panel.

4.10 The Serious Case Review Panel Membership

The Board should ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family. The priority should be to engage organisations in a way which will ensure that important factors in the case can be identified and appropriate action taken to make improvements.

The Board may ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. This will be the agency report (previously known as the IMR).

The Business Manager and SCR Panel Chair will identify the SCR Panel members and convene the first meeting. A core group of agencies will always be involved:

  • Children Services (including Education);
  • Police;
  • Health - Commissioning, provider and the local Hospital.

Representatives of other relevant agencies may be invited to participate where they have had contact with the family e.g.

  • Adult’s social care;
  • Other Health services e.g. CAMHS;
  • Community Rehabilitation Company;
  • National Probation Provider;
  • Probation;
  • Housing;
  • Voluntary agencies;
  • Faith and community groups;

Panel members should be clear about their role and be representative of all relevant key agencies with sufficient seniority to be able to comment on their agency’s practice; commit necessary resources to the review and ensure that recommendations can be taken forward. They must not have been directly involved in the practice or line management of the case.

4.11 Role and Functions of the Serious Case Review Panel

The SCR Panel will undertake the following on behalf of the LSCB:

  • Determine the scope of the review and agree clear terms of reference as recommended by the preliminary SCR panel meeting. (Keep these under review in the light of later information);
  • Select the time period over which the events are reviewed. (If necessary the Panel should revise these in the light of additional information);
  • Set a timeline for completion of the SCR;
  • Identity the agencies and professionals that need to provide reports and identify any additional agencies as more information becomes available;
  • Determine how family members should be invited to contribute to the review, and who will support their involvement;
  • Ensure that agency staff are supported to participate in the review, e.g. by considering holding a meeting at the start of the process for all staff who may be involved to ensure they understand the SCR process, why one is being held and what is required of them;
  • Conduct the scrutiny of agency reports, ideally at a draft stage, to identify gaps in knowledge, resolve conflicting information and request additional information to ensure the reports are of an optimum quality;
  • Ensure that the child’s experience is kept at the heart of the process, specific areas of practice and issues arising in the case are identified and not lost sight of as the review progresses;
  • Agree and use effective arrangements for anonymity;
  • Take into account parallel processes or court processes;
  • Agree arrangements for working with other LSCBs if necessary;
  • Obtain and use any required expert or legal advice effectively;
  • Ensure that any learning is translated into action plans and where appropriate these are immediately implemented;
  • Ensure that learning already implemented is included in the agency reports and action plans;
  • Aim to complete the review within six months, plan for any anticipated delays, ensure extensions are kept to a minimum and that learning is not delayed;
  • Anticipate and plan for the likelihood of public, family and media interest during and on completion of the SCR.

The SCR panel is responsible for the quality, effectiveness and timeliness of the review, and must quality assure all reports and recommendations to ensure single and multi-agency learning takes place.

4.12 Final Report - Selecting the author and publication

The Report author should be an independent person, commissioned by the Panel who is not the Chair of the LSCB or SCR panel. Their role is to support the SCR Panel in analysis of the agency reports and identification of key issues, gaps or omissions. The Report should capture the Panel’s key findings and support the identification of lessons learned.

The Report author is not a member of the SCR panel but may attend Panel meetings to capture the discussion and analysis. This may include:

  • Attending any meetings of workers involved;
  • Attending any agency report author briefings to ensure that agencies support the production of an effective final Report;
  • Attending Panel meetings where agency reports are being considered;
  • Supporting the Panel with the development of analysis, identification of lessons and recommendations.

The Panel may also ask the final report author to follow up apparent gaps in information. The Report author may also be responsible for seeking the views of family members as part of the review, sometimes with another Panel member or the LSCB business manager.

All SCRs should result in a report which is published and readily accessible on the LSCB's website for a minimum of 12 months and thereafter available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or Adults at Risk involved in the case. LSCBs must comply with the General Data Protection Regulations (GDPR) and Data Protection Act 2018 in relation to SCRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders.

LSCBs should send copies of all SCR final reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that an SCR report should not be published, it should inform the Panel which will provide advice to the LSCB. The LSCB should provide all relevant information to the panel on request, to inform its deliberations.

Final SCR reports should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike;
  • Be suitable for publication without needing to be amended or redacted;

The SCR panel should identify someone to take responsibility for debriefing the family, ensuring that they are aware of the plans to publish the Reports and may share the contents with families in advance where appropriate. Decisions about timing of publication should be made by the LSCB in close liaison with other agencies and in line with other processes, particularly the criminal proceedings.

4.13 Including the views of parents and relevant family members

It is good practice for relevant family members to be invited to contribute as fully as possible to the process unless there are clear reasons to exclude or limit their participation. It may include grandparents or siblings who were closely involved with the child and have a useful contribution about the family’s experiences of services. Although this is difficult and painful time for the family, sensitive engagement should be sought. All attempts to engage should be fully recorded in the final report.

Responsibility for discussing and planning the family participation rests with the SCR panel and Independent Chair. The panel should consider how and when it would be best for the family to contribute and who should facilitate their involvement and give feedback to the family.

Families must always be informed that an SCR is taking place and an explanation given about what to expect, media coverage and that their names will be kept confidential. If the family do not wish to contribute or the panel considers it to be inadvisable, the reasons should be fully recorded and included in the overview report. Timing of involvement should be considered carefully, e.g. the opportunity to contribute could be offered after any court processes and the SCR are completed. The boundaries around which members of the family are involved need to be decided at an early stage. It is important not to make commitments to families that cannot be met.

Communication with family members should be face to face wherever possible following communication to explain the purpose of the SCR and invite them to contribute. It is good practice to allow any contributing family members to agree how their views are included and to see the report before it is published. Where possible the final Report should clearly evidence how the family's views have been used to influence lessons learned from the Review.

If there is a criminal investigation and likely criminal trial the timing for interviewing family members will need to be arranged in conjunction with the legal processes. It is important that the SCR panel receives appropriate advice and plans this carefully with the police Senior Investigating Officer taking into account the views of the CPS with support from the Board legal advisor.

4.14 National Panel of Independent Experts

Working Together to Safeguard Children provides for the establishment of a new National Panel of independent Experts to advise Boards about the initiation and publication of SCRs. The guidance makes clear that LSCBs should have regard to the Panel’s advice when making decisions about SCRs, appointing reviewers and considering publication of final reports. The aims of the Panel are to:

  • Bring rigorous independent scrutiny to the system;
  • Help LLSCBs apply the criteria for initiating SCRs;
  • Advise - and where appropriate challenge - LLSCBs when they decide not to initiate an SCR or intend not to publish a report;
  • Report their views to Government of how the SCR system is working.

The Independent Panel came into effect on 1 July 2013 with a remit to bring independent, rigorous scrutiny to the system by advising, supporting and challenging LLSCBs to do better at completing and publishing SCRs. LLSCBs should let the Panel know the outcome of any deliberations about potential SCRs. The Panel may challenge any decision not to initiate an SCR or seek further information from the LLSCB. LLSCBs should also inform the Panel if they have concerns at any time in the course of an SCR about the feasibility of publishing a particular SCR report. The Panel will consider the concerns raised and provide independent advice to the LLSCB. The Panel can be contacted via a dedicated email address:

5. Individual Agency Reports

Working Together to Safeguard Children no longer specifies that agencies should provide written Individual Management Reports (IMRs) for SCRs. However, it does state that "the LSCB may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review". Agencies are therefore still required to provide full information of their involvement in the form of written reports to inform the initial consideration and Review. This requirement to provide written reports may also apply to alternative learning events.

5.1 The aim of the agency report

The agency report should detail their involvement with the child and their family to inform the SCR Report. The aim of the report is to examine individual and organisational practice openly and critically; to see whether the case indicates that changes could and should be made and, if so, how those changes should be effected.

Each relevant agency identified at the Preliminary Panel meeting should provide a separate report of its involvement with the child / family. This should begin as soon as a decision is taken to proceed with an SCR and even sooner if a case gives rise to concerns within the individual organisation or agency. During the review, it may become apparent that further reports are required from agencies not originally identified at the preliminary Panel meeting.

5.2 Who should complete an agency report?

The SCR Panel and Author will decide which agencies should produce a report, based on the extent and nature of their contact with the child / family. The SCR terms of reference will specify which agencies are involved and their expected contribution.

Some of the key agencies represented on LSCBs may have designated officers responsible for undertaking such reports. Where this is not the case, agencies should consider assigning this responsibility rather than wait until the need for an SCR arises.

The report author should be at a suitably senior level to carry authority and be able to undertake the review competently. They should have sufficient knowledge and expertise to analyse their agency’s involvement effectively and make required recommendations for change.

The author should have had no involvement with the case, or have been the immediate line manager of the practitioners involved. (In turn they should be supervised by a manager who also has had no direct responsibilities for the case). Their independence from the case must be explicit, and clearly recorded within their report and the SCR report. The senior officer within the organisation must ensure that the report author is given sufficient time to complete their review with vigour and within agreed timescales as set by the SCR Panel. The findings from the report should be formally accepted by this senior officer who will also be responsible for ensuring that recommendations are acted upon.

If it is not possible to identify an appropriate report author from within an agency the SCR Panel may consider commissioning an external person to undertake the report, maybe through a reciprocal arrangement with a similar organisation in another authority.

5.3 Accessing Agency Records

Once it is known that a case is being considered for an SCR, each organisation/agency should secure all their records, (including electronic records) relating to the case to guard against loss or interference. The agency records are crucial to producing a thorough and effective report. Where a case is still active, or work is being undertaken with other family members, arrangements should be made for practitioners to have access to records, as necessary.

To produce the necessary detailed chronology on which the report will be based the author will need to review all of the records held by their agency in relation to the child and other relevant individuals included in the scope of the review. Every contact between the agency, the child and others included in the review should be included in the chronology.

Designated health professionals should ensure that the SCR panel can obtain the information it needs to complete the review. For health organisations, each Trust will have a process for requesting access to patient records. Accessing records for the subject child and any siblings should not be problematic as the reason for the request is directly connected with child protection, and therefore in the children’s best interests, supported by the United Nations Convention on the Rights of the Child (1989) and the Children Acts of 1989 and 2004.

5.4 Producing the Chronology

The Panel should notify all agencies of the required format for the chronology at the start of the review, confirming required style for dates for the Chronolator. It is important that contributing agencies provide data in a consistent format to simplify merging it into a multi-agency integrated chronology of all contact with the child / family to inform subsequent analysis. This can be done by each agency populating a Chronolator template which can be merged. It is important everyone uses exactly the same format, including date format, font, font size, use of terms, and how names and any other identifying features of the case will be anonymised.

A final column can be used for narrative/comments e.g. to highlight key procedures that were not followed at the time or to note any conflicting information from different agencies or between information gleaned from the case file and that which is taken from interviews. The chronology should not be confined to the information taken only from case files and may include interviewees reports of events that were not recorded at the time. All sources of information should be clearly evident within the chronology.

5.5 Producing the Agency Report

Working Together previously provided a basic outline format for agency reports. A suggested template based on this format is included as Appendix 1: Guidance for Agency Reports.

An early meeting of the SCR panel and agency report authors will ensure that all contributors to the review have fully understood the terms of reference and are working consistently towards the same objectives. The agenda for this meeting could include:

  • Clarifying the reasons for the SCR and ensuring understanding of the process;
  • Identification of all involved organisations;
  • Discussion of each of the terms of reference;
  • Agreement about methods of sharing information with the SCR panel and overview author;
  • Agreement about an approach to anonymising names and any other identifying features of the case;
  • Confirmation of timescales and expected dates of completion of agency reports and completion of the final SCR report;
  • Any contentious issues or disagreements about agency involvement;
  • Any other local issues;
  • Consent arrangements;
  • Confirming the legal support to the review panel.

The Business Manager must ensure that report authors are well briefed and actively address the SCR Terms of Reference within their report. It is good practice to invite report authors to a briefing session prior to commencing their reports to ensure that the Terms of Reference are clear and understood. Good practice should also include inviting report authors to present early draft reports to the SCR panel. Early drafts will also be quality assured by the legal adviser to the Board. This provides an opportunity to address any gaps and engage the independent final report writer in an early dialogue to inform their appraisal and analysis of the agency reports.

On completion of each draft report the senior manager from the relevant commissioning agency, should quality assure the report and feedback to the author to enable any amendments to be made and the final version be submitted on time to the SCR panel. This final version must be signed and dated by the report author and countersigned/dated by the senior manager.

This quality assurance should determine whether the terms of reference have been fully addressed, whether the analysis is appropriate and keeps the child at the centre of the report, whether the leaning is identified appropriately and whether the recommendations for the agency are appropriate. This may also include addressing any feedback given by the SCR panel to ensure the final report meets required standards.

Once the agency's report is agreed as final it should be submitted to the SCR panel in accordance with agreed timescales.

Recommendations should be written in a SMART (Specific, Measurable, Achievable, Realistic, Timely) manner and address the following:

  • What improved outcomes are needed in the agency?
  • What specific actions should be taken by whom, and when?
  • How will the agency ensure that the desired outcomes are achieved?
  • How will senior management know that the actions taken have made the improvements which were needed?
  • Recommendations for ongoing learning, training and audit as a result of findings.

5.6 Agreeing Timescales

Working Together stipulates that: "the LSCB should aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related court proceedings), every effort should be made while the SCR is in progress to: (i) capture points from the case about improvements needed; and (ii) take corrective action"

If statutory timescales cannot be met a revised timeline should be prepared for the LSCB together with reasons for the delay and how learning will be progressed in the meantime.

6. The Systems Approach

The term, “systems approach” implies a far broader concept than policies, procedures and protocols. It’s a holistic which includes all the possible variables that make up the workplace and influence frontline workers in their engagement with families. As well as tangible factors such as procedures, tools and aids, working conditions, resources and skills, a systems approach also includes issues such as team and organisational cultures which are often difficult to identify and analyse.

The factors that influence how a member of staff behaves include:

  • The tasks they perform;
  • The available tools designed to support them;
  • The environment in which they operate;
  • The organisational culture.

The crux of the approach is that it examines human performance in its context and recognises that people’s competence in carrying out tasks to a high standard is influenced by the whole system around them. The work environment should be designed with the aim of making that influence constructive. A systems review or investigation examines how well this has been achieved.

The approach identifies the purpose of SCR or other Reviews as being to get behind what happened in order to understand why it happened, so that the organisations involved can identify and address underlying issues identified. To do this effectively it is important to understand what practitioners thought at the time, what was influencing their assessment of the situation, and what other factors applied.

The approach is based on organising and analysing the complex factors that influence work with children and families. The framework for analysis focuses on the interactions between different parts of the system, through examination of key influences. Working through each part of the system generates ideas about ways of redesigning particular parts of the system to improve children’s safety. The Systems approach can be utilised outside of a standard SCR.

Making recommendations

Understanding complex influences on practice to identify improvements can require change from people at all levels of the system, not just from frontline workers.

Three different kinds of recommendations emerge from a systems case review:

  1. Issues with clear-cut solutions that can be addressed locally and by all relevant agencies e.g. creating a consistent rule across agencies of a particular administrative process.
  2. Issues where solutions cannot be so precise because competing priorities and resource constraints mean there are no easy answers e.g. if we want more attention to be given to the critical aspects of the supervisor’s role, and agencies cannot assume spare capacity.
  3. Issues that require further research and development in order to find solutions, including those that would need to be addressed at a national level e.g. addressing problems in new software would require experimentation to find solutions through more user-centred design.

Some Examples of Models that may be considered:

  • SCIE Learning Together (LT) has been piloted and evaluated during the Working Together consultation period and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved.
  • Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened.
  • Significant Incident Learning Process (SILP) (see Review Consulting Website) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews.  This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case,  accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’.
  • Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR’s conducted as an appreciative inquiry seek to create a safe, respectful and comfortable  environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong.  They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.

7. Parallel Processes

The SCR and other Review Panels should be take account of any parallel processes that are ongoing at the same time as the Review and ensure that their impact is managed actively so as not to create avoidable delay.

7.1 Working with other authorities – SCRs across multiple LSCB areas

It is possible that, due to family mobility, other authorities may have worked with the child / family at some point in the past, and contributions to the SCR will be required. This makes the review more complicated, but providing the following steps are undertaken, should not hamper or delay the production of the SCR:

  • Be absolutely clear about which authority is the lead for the SCR at the start;
  • Be clear about expectations of other LSCBs – in some cases a full chronology and reports will be required, in others a short summary of involvement will suffice;
  • Agree specific approaches to issues at the outset, for example, communication lines, publicity and dissemination strategies, confidentiality, media interest etc;
  • Establish a lead liaison officer from other LSCBs - if a number of agencies are involved in another LSCB area, one lead officer is essential;
  • If necessary, hold regular meetings of each of the LSCB representatives to review the work and receive progress reports.

7.2 Coroners involvement/ Criminal Court Proceedings/ Domestic Homicide Reviews/ Vulnerable Adult Reviews, Health Agencies Serious Incident Reviews

These processes may also be taking place in parallel with the SCR. At an early stage the SCR Panel Legal adviser should contact the Coroner’s office, the Crown Prosecution Service or Police lead etc to agree any co-ordination needed between the processes such as timing of actions and disclosure of information.

There should be agreement about when to release specific information, to co-ordinate the timing in relation to court processes – particularly in relation to interviewing staff for the SCR who may also be witnesses in a current police investigation and to ensure there is regular review of this information in response to changing circumstances.

These processes should not delay progress of the SCR unless vital information is awaited which cannot be identified other than through these routes. Court processes will always attract media attention so agreement about media strategies is crucial. The responsibility for conducting Domestic Homicide Reviews lies with the Community Safety Partnership. There is approved formal guidance, setting out the process to be followed and recognising the links to the Safeguarding Children and Safeguarding Adult’s Boards. Close liaison will be required between the three bodies to ensure that any overlapping processes/duplication is avoided. This is particularly applicable in complex cases e.g. where both an adult and child may have been victims of assault by the same perpetrator.

8. Media Strategy

It is essential to have a media strategy in place. Information may be given to the press before official publication, e.g. from family members or leaks from one of the participating LSCB agencies and the Panel should be prepared for this. Advice about specific media liaison and publicity will be co-ordinated by the LSCB and a named media person from one agency. Important points to consider are:

  • Good communication between media / publicity departments across LSCB agencies;
  • Clear briefings for panel members and “talking heads” elected members, so that all concerned are fully aware of when to expect media coverage;
  • Clear communication with family members about the publication;
  • Clarity about who will lead the media response and the high level messages;
  • Thoughtfulness about the actual wording of reports that will be published;
  • Co-ordination with media releases from any other LSCBs or agencies involved;
  • Training in working with the media for high profile SCRs;
  • A schedule of briefing dates to be circulated to relevant media.

9. Learning from Serious Case and other Reviews

As much effort should be spent on acting on recommendations as on conducting the actual Review.

The following should help to secure maximum learning from the review and feed into the learning and improvement plan:

  • Conduct the review in such a way that the process is a learning exercise;
  • Consider what information needs to be disseminated, how, and to whom, in the light of a review;
  • Be prepared to communicate both examples of good practice and areas where change to practice is required and ensure they are enshrined in the training agenda;
  • Focus recommendations on a number of key areas with specific and achievable proposals for change and intended outcomes;
  • Ensure robust monitoring of the resultant Action Plan to ensure identified changes/ improvements are implemented and embedded;
  • Day to day good practice can help ensure that reviews are conducted successfully and in a way most likely to maximise learning;
  • Promote a culture of audit and review to gauge the extent to which change is embedded in improved practice;
  • Establish clear, systematic case-recording and record-keeping systems;
  • Develop good communication and mutual understanding between different disciplines and different LSCB members;
  • Communicate with the local community and media to raise awareness of the positive and ‘helping’ work of statutory services with children, young people and their families so that attention is not focused disproportionately on tragedies;
  • Make sure staff and their representatives understand what can be expected in the event of an SCR.

9.1 Action Plans

The SCR Action Plan will be developed directly from the recommendations of the final report. It will include all the individual agency report recommendations and any overarching cross cutting recommendations for more than one agency. The Action Plan should be realistic and set out clearly the responsible agencies/individuals and specific dates by which actions will be undertaken, as well as the desired outcomes.

The LSCB standing sub- group (SIRG) is responsible for monitoring the SCR Action Plan through regular review until completion. Individual actions will be signed off as they are completed.

The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

9.2 Disseminating lessons learned

The final report can be useful both as a training resource and as the basis for discussion in individual team meetings. It is particularly useful to disseminate the findings amongst staff groups who were involved with the SCR. A meeting should be held with the staff involved to confirm that the review is complete and outline the findings, either on a multi-agency basis or by each agency separately.

9.3 Embedding the learning

Ensuring the embedding of lessons/practice changes is not easy. There is a danger that SCR findings, recommendations and action plans have an immediate and short term impact but the learning is not sustained. The LSCB SIRG, in conjunction with the Policy, Performance, Education and Training (PPET) Sub-Group has responsibility for reviewing SCRs to identify lessons and disseminating them appropriately. The PPET group maintains an overview of all multi - agency audit activity, including those that examine how well actions from previous SCRs, including SCR’s from other areas, have been embedded to change practice.

10. Action Following Completion of the Review

Following completion of the Review and sign off by the LSCB the final report should be published on the LSCB website. The report should also be sent to the National Panel of Independent Experts at least one week before publication.

Appendix 1: Guidance for Agency Reports

The headings below may help to guide the preparation of agency reports. They provide a basic format although there may be specific areas in individual cases which require further exploration.


A chronology of the agency’s contact with the family using an agreed template. This can be used as the basis for producing the report.

The following comprise the five main components to the report.

1. Introduction

The introduction should name the child and give details about age, ethnicity, relevant family members and the circumstances which precipitated the review. This section should describe the position of the report author to explain their independence in relation to the case, the process undertaken in preparing the report and should list the names of those interviewed and other sources of information, e.g. the child’s case file.

2. Narrative

Using the chronology as the basis the narrative should describe the sequence of events and critical incidents for the child / family, and the actions taken by the agency in response. This narrative provides the second section of the report - the actual chronology should be provided as an appendix.

3. Analysis of involvement

The analysis should consider the events that occurred, decisions made, and actions taken or not taken. Where judgments were made, or actions taken, which indicate that practice or management could be improved, the analysis should aim to provide an understanding of what happened and why.

The following factors, although not exhaustive, should be considered in the analysis:

  • Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?
  • When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken into account when making decisions about the provision of services? Was this information recorded?
  • Did the organisation have policies and procedures in place for safeguarding and promoting the welfare of children and acting on concerns about their welfare?
  • What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?
  • Did actions accord with assessments and decisions made? Were appropriate services offered or provided, or relevant enquiries made, in the light of assessments?
  • Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services?
  • Where relevant, were appropriate child protection or care plans in place, and child protection and / or looked after reviewing processes complied with?
  • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family? Were these explored and recorded?
  • Were senior managers or other organisations and professionals involved at points in the case where they should have been?
  • Was the work in this case consistent with each organisation’s, and the LSCB’s, policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?
  • Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations?
  • Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?
  • Was there sufficient management accountability for decision making?

4. Lessons learned / findings or conclusions

This section should provide the conclusions and whether there are lessons learned from the events and analysis in relation to the way the organisation works to safeguard and promote the welfare of children. Instances of good practice should be highlighted, but the main body of this section will outline means of improving practice and policy. This section should include the main messages and implications for systems and processes, and for practice, including for example, management and supervision, multi-agency working, resources, training and development. If there are shortfalls in service which the panel is assured have been addressed since the incident this must be recorded and spelt out if a recommendation is not to be made. Findings should be numbered and relate directly to a recommendation or a reason given as to why a recommendation is not necessary.

5. Recommendations

The recommendations should be SMART and outcome focused, so that the responsible senior manager in the agency can draw up an action plan outlining the actions to be taken; by whom, and when, in order to meet specific outcomes. This section should also include how the organisation will evaluate whether the desired outcomes have been achieved.

Other considerations

The five components above comprise the main elements and must be addressed in all reports. Agencies may also provide additional information to set the context for the report, e.g. particular management arrangements or frameworks which were in place and relevant or particular circumstances which may have impinged on the events, such as staffing difficulties within the organisation. Set out on the following pages is a basic template for use by report Authors.

Appendix 2: Significant Incident Notification Form

Appendix 2: Significant Incident Notification Form

Appendix 3: Incident Notification Form

Appendix 3: Incident Notification Form