By Lorna Ponambalum, Safeguarding Consultant

Child Safeguarding Practice Reviews (SPRs) formerly called Serious Case Reviews (SCRs)

We are all responsible for Safeguarding! – The sad case of Victoria Climbie

Many of you will have heard of the shocking case of Victoria Climbie.  Victoria’s life was short and tragic. She was abused and murdered by her great-aunt and her great-aunt's boyfriend.
Her death prompted a public inquiry and the largest review of child protection arrangements in the United Kingdom.
Victoria was born in the Ivory Coast. At the age of 7 she arrived in Paris to live with her great-aunt Marie-Thérèse Kouao. The pair travelled to England in April 1999 where they met Carl Manning who became Marie-Thérèse Kouao’s boyfriend. It is not exactly known when the abuse started but it is widely thought that it worsened when Victoria and her great aunt went to live in the boyfriend’s flat in Haringey, North London.
Throughout the abuse, Victoria was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers, and wires. A number of agencies including the Police, Social Care from four local authorities, members of a local church community and even the National Society for the Prevention of Cruelty to Children (NSPCC) had contact with her and noted the signs of abuse. However, neither of them decided to further investigate or take any action.
After months of torture, Victoria died of hypothermia at her aunt's flat. She had 128 injuries all over her body. She was just 8 years old. The Home Office pathologist who later examined her corpse described the case as "the worst case of child abuse" he had ever seen.

The Laming Report – Lessons that needed to be learnt by all Professionals

Following Victoria’s death, a public inquiry, headed by Lord Laming, was ordered. During the inquiry it was discovered that there were several opportunities where Victoria could have been saved and where organisations failed their duty of care. Lord Laming made 108 recommendations relating to child protection in England, of which he says 46 should be implemented within three months, 38 within six months and the rest within two years.

The key recommendations are:
·         The creation of a ministerial Children and Families Board, to be chaired by a Cabinet minister.
·         A new National Agency for Children and Families, rather than a Child Protection Agency, that would report to the ministerial board about all aspects of child welfare.
·         A Children's Commissioner for England, who would run the Agency.
·         The creation of a national database on children under 16, recording all those who come into contact with child protection services.
·         A Government review of the law regarding the registration of private foster carers.
·         Each local authority must establish a Committee for Children and Families with members from the police authority, council, and health service trusts.
·         New social work degrees.
·         Better sharing of information by agencies which can currently be hindered by the Data Protection Act and Human Rights Act.
·         Shorter clearer guidance to one million professional staff dealing with protecting children.
·         Random inspections by senior managers of case files; social workers must check information from all child protection agencies before doing home visits.
·         Local authorities must make child protection available 24 hours a day and advertise a 24-hour free telephone referral number by members of the public.
·         Hospital chiefs must ensure no child suspected of having been abused is discharged without a plan for their future care.
·         Child protection must be included in the list of ministerial priorities for the police.

Changes to Legislations

Furthermore, Victoria’s death also prompted the introduction of the Every Child Matters initiative and the amendment of the Children Act 1999 which subsequently became the Children Act 2004. What also was established under the Children Act 2004 were Serious Case Reviews (SCRs). Since 2018 the structure of these reviews has changed because of amendments made to the Working Together to Safeguard Children (Department for Education, 2018) guidance. Now they are referred to as Child Safeguarding Practice Reviews (SPRs).

Responsibility for learning lessons lies with a new national panel – the Child Safeguarding Practice Review Panel (the Panel), which was also set up by the Department of Education in 2018. 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 aim of Child Safeguarding Practice Reviews (SPRs) are to learn lessons to help prevent future similar incidents as well as help professionals within organisations improve the way they work together to safeguard children.
In addition to the Child Safeguarding Practice Review Panel (known as the Panel) who is responsible for these reviews at national level, there are local safeguarding partners who are ultimately responsible at a local level.

A Child Safeguarding Practice Reviews (SPRs) previously known as Serious Case Reviews 

A Child Safeguarding Practice Reviews (SPRs) should take place if abuse or neglect is known, or suspected, to have been involved and the following has happened:
·         A child has died.
·         A child has been seriously harmed and there is cause for concern about how organisations or professionals work together to safeguard the child.
·         The child dies in custody.
·         A child has died by suspected suicide.

If any of the above criteria has been met, then the local authority should report the incident to Ofsted and the relevant Safeguarding Partnership or Partnerships within five working days of becoming aware that the incident has occurred.
At a local level, the safeguarding partners are expected
·         to identify and think about serious child safeguarding cases whose specific issues impact on the local area.
·         commission and oversee child safeguarding practice reviews of those cases, where they consider it to be appropriate.

The safeguarding partners then begin a rapid review of the case to identify any necessary action required to ensure a child's safety and consider what potential lessons could be learnt from carrying out a Child Safeguarding Practice Review. Gathering this information will enable a decision to be made about whether it is necessary to carry out a Child Safeguarding Practice Review.
The local safeguarding partners will also liaise with the National Child Safeguarding Practice Review Panel(the Panel) to discuss and agree whether a case may raise issues which are complex or of national importance such that a national review may be appropriate
A local Child Safeguarding Practice Review are not automatically carried out despite meeting the criteria. Consideration in deciding whether or not the incident is serious is decided using the definition set out in Working Together to Safeguard Children (Department for Education, 2018 document. Decisions on whether to commence a review should be made transparently and with a view that all parties involved including families are clearly informed of the rationale behind it.
Once it is confirmed that a Child Safeguarding Practice Review will be conducted, the local safeguarding partners will agree on the methodology to be used and must ensure that practitioners, families, and surviving children are fully involved. Participants in reviews should be invited to contribute their perspectives without fear of being blamed for actions they took in good faith.
The final report from a Child Safeguarding Practice Review is expected to be completed and published within 12 months.

The report will include
·         a summary of any recommended improvements to be made by persons in the area to safeguard and promote the welfare of children
·         a detailed analysis of why actions were taken or not in response to the information gathered throughout the process

The recommendations made will be ultimately focus on improving outcomes for children.
Furthermore, local safeguarding partners can also carry out Multi-Agency Case Reviews or Partnership Reviews which do not meet the criteria for a Child Safeguarding Practice Review, but are considered to offer good opportunities to identify lessons for learning and ways in which multi-agency practice to safeguard children and young people can be improved locally.

The Child Safeguarding Practice Review Panel (The Panel) which operate at a national level is responsible for:
·         identifying serious child safeguarding cases which raise issues that are complex or of national importance
·         overseeing the review of these cases
·         setting up a group of potential reviewers who can undertake national reviews, a list of whom must be publicly available
·         agreeing the potential scope and methodology of the review with the local safeguarding partners and engaging with them and others involved in the case.

The Child Safeguarding Practice Review Panel are also responsible for providing guidance on how to conduct a local child safeguarding practice reviews and serious case reviews. The guidance was published in April 2019 and is titled “Child Safeguarding Practice Review Panel: Practice Guidance”

The Child Safeguarding Practice Review Panel regards a ‘good’ review report as one that includes:
·         a brief overview of the key circumstances, background, and context of the case
·         a summary of why relevant decisions by professionals were taken
·         a critique of how agencies worked together and any shortcomings that were identified
·         consideration of whether any shortcomings are features of practice in general
·         consideration of what would need to be done differently to prevent harm occurring to a child in similar circumstances
·         recommendations for what needs to happen to ensure that agencies learn from this case (Child Safeguarding Practice Review Panel Guidance, 2019)

The role of all agencies in relations to the Child Safeguarding Practice Review

Local safeguarding partners should highlight findings from reviews with relevant agencies including the Police, Housing, the Church, Health, Social Care and Education, Youth Offending to name but a few. The outcomes and any actions for improvements should be disseminated across all agencies through training or briefing events. There should also be a regularly audit progress on the implementation of recommended improvements. The improvement should be sustained through regular monitoring and follow up of actions so that the findings from these reviews make a real impact on improving outcomes for children and young people.
However, research and outcomes of SCRs and SPRs have repeatedly shown the dangers of agencies failing to take effective action:
These include:
·         failing to re-assess concerns when situations do not improve
·         Failing to listen to the views of the young person
·         Lack of challenge to those who appear not to be taking action
·         Poor record keeping
·         Sharing information across agencies too slowly or not at all
·         Failing to act on and refer when there are early signs of abuse and neglect

Case Study – Serious Case Review ‘EML’ 26.11.19

A recent example of, as it was called then, a Serious Case Review took place in a London Borough where a 17.5-year-old white female (known as EML in the review) with an “extensive history of sometimes life-threatening self-harm was hit by a train and killed in April 2018. EML had been a patient at specialist mental health unit(Tier 4 Unit) where she had been compulsory detained under S.3 (Treatment) of the Mental Health Act 1983. On the day of her death, EML had been given S17 ‘leave of absence’ from the unit and was accompanied home by a friend. Following an inquest into her death in September 2018, the Coroner’s conclusion was that EML had died by suicide.
Throughout her short life EML self -harmed on 48 occasions, the first one was when EML was 14 years old and there were 4 episodes which were described as life threatening.
EML had been affected by three significant events in her life. In 2003 her paternal aunt had died by suicide and her maternal grandfather had passed away of natural causes in 2013. In 2013 her maternal grandmother came to live with the family as she had been diagnosed with dementia.
EML was in March 2016 detained under S2 of the Mental Health Act which was then converted to S3(Treatment) in April 2016.
EML was admitted to two Tier 4 Units. One was located 60 miles from EML’s home, the other in North London.

A number of agencies were involved in her care
·         EML’s local authority Children Social Care
·         CAMHS (Child and Adolescent Mental Health) from three local authorities
·         Highfield Centre, Oxford (A Tier 4 Unit)
·         Beacon Centre, North London (A Tier 4 Unit)
·         Education – School
·         LA Pupil Services
·         NHS England
·         LA Safeguarding Children Board (LSCB)
·         LA Clinical Commissioning Group (CCG)
·         Barts Health NHS Trust
·         Whittington Health Trust
·         Oxford Health NHS Foundation Trust
·         The Police

Issues raised in the review cited

·         At times poor coordination of care and support
·         Some involvement of LA Social Care was appropriate although there was a thought that given the number of agencies involved, Social Care could have fulfilled the role of a coordinator/facilitator
·         The extent of Community CAMHS involvement with the case
·         Perceived poor communication and a failure to share information between certain services such as between the Beacon and the secondary school
·         Issues about clarity of roles such as the Community CAMHS
·         Scope for more informed appreciation of the experiences, wishes and feeling of EML in planning especially about her transition to Adult Services
·         LCSB to alert agencies to training so that the complexities of the Children Act 1989, Mental Health Act 2003 and the Mental Capacity Act 2005 along with the Liberty Protection Safeguarding (LPS) are better understood by professionals
·         LSCB should alert NHS England about the negative consequences of unavailable local Tier 4 provision
·         Concerns about insufficient documentation of communication between services
·         Concerns about record keeping of significant events and communication between agencies
·         Concerns about information sharing and effective multi agency work
·         Critical failure to ensure an effective multi-agency partnership in EML’s planned return to school in late 2016 / early 2017.
·         Concern raised by EML’s parents that her eating disorders was understated in the review and the early use of services to address this were not utilised early enough.
·         Some disagreement between professionals over the Autistic Spectrum Disorder (ASD) diagnosis.

The reviewer concluded the following:
In summary EML’s premature and tragic death by suicide was predictable, but occurred in spite of enormous effort expended by dozens of skilled and conscientious professionals working predominantly through not entirely, effective partnership, with a loving and committed family

The role of Education in relations the Child Safeguarding Practice Review

It is important for Designated Safeguarding Leads and other colleagues with responsibility for safeguarding in schools familiarise themselves with learning from Child Safeguarding Practice Review (SPRs)as it is important to improve the ability to promote the welfare of children and young people.

Under Working Together to Safeguard Children’s new arrangements, the education sector is viewed as a ‘relevant agency’ but not a statutory partner. However, we know that schools are constantly reviewing policy and practice of safeguarding. Using the outcomes of the Child Safeguarding Practice Review will help inform the process of learning and thinking strategically about promoting the welfare and well-being of children and young people in their care.

Learning from the Analysis of Serious Case Reviews

The Social Care Institute for Excellence has recently published a new resource for schools. The document is a summary of the government's 3-year analysis of Serious Case Reviews (SCR) (2020), specifically drawing out the important learning for schools, school leaders and DSLs.
This analysis draws together key trends and emerging themes that have arising from reviews that were conducted following the death of a child, or instance of a child coming to serious harm, because of abuse or neglect. 368 Serious Case Reviews, involving a total of 404 children, were reviewed by government research between April 2014 and March 2017. The report was published in March 2020.
The report aimed to:
           recognise common themes and trends across all Serious Case Review reports.
           sample reviews to better understand systemic strengths and vulnerabilities of practice.
           examine the impact of policy changes and initiatives; and
           Evaluate the degree to which recommendations from reviews have been implemented and any impact on practice of these changes.

The Serious Case Review analysis for the education sector can be found here:

The NSPCC also have a plethora of thematic briefings which highlight learnings from case reviews that have been carried out when a child dies or is seriously injured and abuse or neglect are suspected.
The briefings are a series of pertinent safeguarding topic with each briefing drawing together key risk factors and practice recommendations to help practitioners develop their understanding and respond to the learning from case reviews.
The NSPCC briefings can be found here:



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