Serious Case Reviews (SCRs) and Case Reviews

What are Serious Case Reviews?

A Serious Case Review (SCR) is a review of services that have been provided to a child and family prior to the death or serious injury of a child where abuse or neglect are believed to be a contributory factor.  LSCBs are required to undertake Serious Case Reviews under regulation 5 of the Children Act 2004 and guidance for this is contained in Chapter 4 of Working Together to Safeguard Children 2015.

The purpose of a SCR 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 safeguard 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, to improve inter-agency working and better safeguard and promote the welfare of children.

A SCR is undertaken by a SCR Panel, chaired by a person independent of the different agencies involved.

Learning Lessons from Serious Case Reviews (SCRs)

SCRs often find a combination of good service provision and practice, alongside lessons to be learned about how these can be improved to help ensure that such events do not happen again.   Members of the LSCB are enabled to take these lessons back to their agencies to disseminate the learning.  This learning is also cascaded through single and interagency training and development, as well as through the implementation of the action plans, briefing notes etc. The Department for Education (DfE) produced a Research Report in 2014 which considers how front-line practitioners and partner agencies use findings from serious case reviews (SCRs) within policy and practice, and what barriers prevent some recommendations from being carried out.

National Panel of Independent Experts

Since 2013 there has been a National Panel of independent experts to advise LSCBs about the initiation and publication of SCRs. The role of the National Panel is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through publication of final SCR reports.  The National Panel also reports to the Government their views of how the SCR system is working. The National Panel’s remit includes advising LSCBs about: •  application of the SCR criteria; • publication of SCR reports. The LSCB consider the panel’s advice when deciding whether or not to initiate an SCR, when appointing reviewers and when considering publication of SCR reports.  The LSCB complies with requests from the panel, including requests for information such as copies of SCR reports and invitations to attend meetings. More information about the National Panel and its work during the first year of operation can be read in its Annual Report 2014 and last year in its Annual Report 2015.

Publication of Serious Case Reviews

From 2013, LSCB’s were required to publish final Serious Case Reviews reports, completed since 2013, so that the learning is shared as widely as possible.  For SCRs undertaken prior to 2013, an executive summary report has been made available.   SCRs undertaken by Redbridge LSCB were in 2008 (Child ‘H’) and 2009 (Child ‘L’).  Executive summary reports on these are available via the NSPCC Serious Case Review National Repository (see further information below).

A further SCR was undertaken in 2019 and the report was published on 14 January 2020:

Learning from other LSCB SCRs

The publication of reports means that the learning from SCRs held in other parts of the country can be shared more effectively.  The NSPCC have developed a portal of all published SCR Reports.  The NSPCC has also produced a series of thematic briefings which highlight the learning from case reviews that are conducted when a child dies or is seriously injured and abuse or neglect are suspected. Each briefing focuses on a different topic (e.g. CSE, Neglect, Mental Health), pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from SCRs.

In 2014, the Department for Education (DfE) published “Pathways to Harm, Pathways to Protection: The Triennial Analysis of Serious Cases Reviews, 2011 – 2014”.  Research in Practice (RiP), in partnership with the University of East Anglia and Warwick University, has developed an open-access website which includes a number of resources to support the sharing of the findings from the report.  These include an introductory video and individual films for LSCBs, social workers and early help practitioners,  police and criminal justice agencies, health and education.

The LSCB Learning and Improvement Sub Group have developed a template to capture the outline of nationally published SCRs to enable dissemination of findings, lessons etc. The template can be used by all partners.  The Sub Group will from time to time share learning via this format.

Case Reviews

Working Together 2015, Chapter 4, states that LSCBs should also conduct reviews of cases which do not meet the criteria for an SCR, but which can provide valuable lessons about how organisations can work together to safeguard and promote the welfare of children. Although not required by statute these reviews are vital in highlighting good practice as well as identifying improvements which need to be made to local services. In Redbridge, such reviews are conducted either by a single organisation or by a number of organisations working together.


NB:  Following the enactment of the Children and Social Work Act 2017, Serious Case Reviews (SCRs) will shortly be replaced by Local Learning Inquiries (LLIs) and National Serious Case Inquiries (NSCIs), accompanied by a new national learning framework which should improve the robustness and consistency of these important exercises.  More information will be shared on our news page once available.