The following document provides you with information on:
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When serious case reviews (SCRs) are undertaken;
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The Purpose of serious case reviews;
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What happens after a serious case review;

Serious Case Reviews - A Local Perspective; and

Serious Case Reviews - A National Perspective.
When are Serious Case Reviews Undertaken?
LSCBs are required to consider undertaking a Serious Case Review (SCR) whenever a child dies and abuse or neglect are known or suspected to have taken place. Other circumstances that may lead to a SCR are:
 A child receives a potentially life-threatening injury or serious impairment of their health, as a consequence of abuse or neglect (relevant SCR -
East Riding - Child F )

A child is subjected to serious sexual abuse (relevant SCR North
Somerset - Abuse of pupils in a first school (overview report)

A parent has been murdered and a homicide review has been initiated
(relevant DHR - Sheffield DHR )

A child has been killed by a parent with a mental illness (relevant SCR
Kirklees - Child aged 2 years 7 months )

There are concerns about the way different organisations worked together (relevant SCR Flintshire - Sion D (executive summary)
Purpose of Serious Case Reviews
Serious case reviews are not inquiries into how a child died or who is culpable; these are matters for coroners and the criminal courts, respectively.
Working Together 2013 calls on LSCBs to maintain a local learning and improvement framework that enables organisations to be clear about their responsibilities, to learn from experience and improve services as a result. A

serious case review is one of the ways in which the LSCB can look at what happened and why.
The purpose of a Serious Case Review 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;
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Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and
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Improve intra- and inter-agency working and better safeguard and promote the welfare of children.
What happens after a serious case review?
Once the SCR is completed and before its publication, the SSCB SCR sub group translates the recommendations into an action plan. Senior managers within each of the organisations are actively involved in implementing the action plan with progress captured at each of the SCR sub group meetings.
A copy of the executive summary which accurately reflects the full overview report is then made publicly available.
The executive summary and key findings are disseminated to relevant interested parties, and feedback given to the child (if surviving) and family members/carers. Relevant staff are also given feedback and debriefed.
The SSCB SCR sub group regularly monitors and audits the actions of those agencies involved against the action plan. Agency representatives are required to provide regular updates on actions with examples of evidence where possible including impact on practice.
Serious Case Reviews – A local Perspective
Since 2008 Staffordshire Safeguarding Children Board has completed four
SCRs. Out of the five children involved in the reviews, four survived and one child died as a result of suicide. At the time of the incidents, 2 of the children were under the age of 12 months, one child was aged 3 years and 9 months and two children were teenagers.
The issues that were prevalent in the families of the children that were the subject of SCRs in Staffordshire reflect national findings. The main issues identified related to parental / carer needs arising from either or a combination of:
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Substance misuse;

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Domestic violence; and /or
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Mental health needs.
I n most of the SCR’s more than one of the above was present. When dealing with families who have all 3 of the above, the term toxic trio 1 is used.
All of the SCR’s reminded agencies about the need to consider the whole family and the risk of the ‘start again’ syndrome – particularly in respect of safeguarding children from neglect.
Executive summaries for all of these cases can be found at: www.staffsscb.staffordshire.gov.uk/Professionals/Case-Studies-Case-
Reviews/Case-Studies-Case-Reviews.aspx
Serious Case Reviews - A National Perspective
During April 2010 to March 2011 there were 117 serious case reviews nationally. These involved 150 children, of which 69 died and 81 were involved in serious incidents. A total of 119 of the 150 children were already known to Children’s Social Care Services.
The majority of children were under 5 years of age or younger (51 under 1 year old & in 31 the baby had died) and 28 were young people aged 14 years or older (a ¼ died).
Similarly, Ofsted conducted a thematic analysis of 482 SCRs during April
2007-March 2011 to explore lessons to be learnt and found that of the 482 cases / 602 children: 210 children (35%) were babies under 1 year old (a consistent pattern) & 111 (18%) were young people over the age of 14 years.
This report highlights key safeguarding issues in relation to babies less than 1 year old and young people aged 14 or above. This research illustrates the range of diverse reasons that have led to child deaths or serious injuries and to serious case reviews, and explores the different vulnerabilities of these particular two groups of children. Issues discussed for babies include;
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The role of pre-birth assessments;
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The role of parents;
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The contribution of health agencies; and
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The particular vulnerability of babies.
The analysis of cases involving young people over the age of 14 focuses failings of the professional to treat the young person as a child in need.
1 The term 'Toxic Trio' has been used to describe the issues of domestic violence, mental illhealth and substance misuse which have been identified as common features of families where harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people.

The lessons learned through the SCR process in other areas of the country can be relevant to our practice in Staffordshire. All SCRs published nationally on LSCB websites across the country are available on the NSPCC website:
SCRs 2010
– please click on this link to go to this external website.
Similar issues are arising nationally in SCRs as noted in Marion Brandon's report for the former DCSF, Understanding Serious Case Reviews and their
Impact 2005-7: A Biennial Analysis of Serious Case Reviews 2005-7 (PDF,
505KB) .
Key findings of the 47 cases studied in detail from the last DCSF Review indicate that:
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Domestic violence was present in 66% of cases
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Substance misuse was present in 57% of cases
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Mental ill health was present in 55% of cases
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All three issues were present in 34% of cases
What learning do we take from this now….
Ofsted published its evaluation of the lessons learned from SCR’s between
April 2009 -2010 2 and identified six main messages which reoccur throughout the reviews. The messages are about the importance of:
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Focusing on good practice;
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Ensuring that the necessary actions take place;
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Using all sources of information;
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Carrying out assessments effectively;
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Implementing effective multi-agency working; and
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Valuing challenge, supervision and scrutiny.
Local Learning and Developments
Of the four SCR in Staffordshire, the following recommendations emphasise the work undertaken from the last two SCR’s. This work underlines the need to review practice and take action to address the issues raised.
The following information offers you a number of examples of how this has been achieved:
SCR Teenage Suicide
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Shared care projects facilitate the messages surrounding issues such as the safe storage of methadone, with agreed protocols around specific harm reduction activities that aim to further embed this approach;
2 Learning Lessons from Serious Case Reviews 2009-2010 Ofsted October 2010

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A targeted campaign highlighted the risk of methadone amongst drug users and the wider public as well as raising awareness with those agencies that may not normally come into contact with drug users;
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Paediatric staff have had updated training around children who self-harm;
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Operational plans have been developed for children who go missing to assist staff on paediatric wards;
 Best practice workshops are being delivered in pupil referral units (PRU’s), short stay schools and other educational settings;
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Childr en’s Social Care (CSC) quality assurance processes reflect the lessons learned from national and local SCRs;
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The CSC assessment framework procedures have been revised to support team managers in making decisions about those cases where there have been 3 initial assessments on the same child;
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There has been a review of the current guidance that offers support to staff who are responding to an incident of self-harm and where a child discloses an intent to commit suicide;
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There has also been work around lowering the violation threshold (specific to ICT) for schools as this allows them to be more informed when dealing with safeguarding concerns as pupils use the internet. Level 1 training to schools reinforces the importance of sharing information between key staff such as the ICT staff and the child protection designated lead;
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Highly resistant families practice guidance aids staff in understanding and implementing the processes regarding non-compliance and child protection processes when dealing with chaotic and resistant families;
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In addition, the Hidden Harm steering group are developing a information sharing protocol between adults and children’s services in line with recommendations from the Drug Misuse and Dependence UK Guidelines on Clinical Management;
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A revised SSCB Highly Resistant Families Practice Guidance is now available on the SSCB website;
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Case reviews within each of the agencies are carried out regularly to highlight issues such as links with criminal activity and/ or anti social behaviour and those parents who have substance misuse issues and have responsibility for children;
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Search booklets used by Staffordshire Police now contain an additional paragraph that provides guidance on safeguarding children when carrying out police searches, executing warrants and associating premises;
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Staffordshire Police has carried out a scoping exercise to review the uptake on level 1 child p rotection training with PCSO’s and as a result there has been a greater uptake of this course, with any gaps fed back into the SSCB workforce development and training sub group;
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Relevant agencies have undertaken a review of their protocols in terms of prescribing and storage of substances and supporting pregnant learners

under the age of 19. Those that have been updated have been widely disseminated across the health service groups;
 Hidden Harm is one of the SSCB’s strategic priorities for 2012 -2013, which has resulted in the development of a hidden harm standing group which considers awareness raising, training and the commissioning of educational materials;
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Further work around a draft strategy to reduce suicides and self-harming in adolescents has begun and links to the public health team will help to drive this forward;
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The SSCB Performance Management Strategy Action Plan 2011-12 incorporates a requirement for thematic audits to include a focus on agencies compliance with LSCB procedures;
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SSCB provides regular training on serious case reviews including lessons to be learned on its annual training programme and these are consistently updated to reflect current findings both nationally and locally;
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Through training and other communication strands practitioners are encouraged to maintain and increase their professional curiosity and respectful uncertainty when working with children and their families;
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Further in depth training has been delivered to specific agencies such as schools, housing officers and income and neighbourhood teams to help embed key messages around record keeping, money matters and thresholds as well as dealing with cases where there is domestic abuse, parental substance misuse, mental health issues and self-harm;
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SSCB SCR briefings are regularly shared with all agencies and provide an opportunity to share lessons and improve practice as they are used in supervisions, staff meetings, training and action plans that link to and inform other pieces of work;
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Regular updates can be found on the S SCB website under ‘Latest News’ as well as reports within the SSCB bi-monthly newsletter;
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The updated SSCB inter agency escalation procedure provides a supportive framework that aims to address the resolution of disputes and encourages practitioners and managers to appropriately challenge and hold each other to account;
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Work is on going with the Health and Wellbeing Board to consider how effective commissioned services support and deliver resilience in young families, including details of how they support the positive engagement of both parents in preparing for birth and caring competently after birth.
Reports will be submitted to the SSCB.
SCR - 9 week old baby
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Community Paediatrician Child Assessment Protocol for named Health
Visitors has been developed and highlights the issues faced when child

health assessment appointments do not take place or where a health visitor is not available;
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Updated guidance ensures that the child health records are transferred and received by the community paediatrician within 72 hours prior to the child health assessment when a health visitor is not available;
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Case reviews within each of the agencies are carried out regularly to highlight issues such as when a learner under the age of 19 becomes pregnant;
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The SSCB Performance Management Strategy Action Plan 2011-12 incorporates a requirement for thematic audits to include a focus on agencies compliance with LSCB procedures;

SSCB provides regular training on serious case reviews including lessons to be learned on its annual training programme and these are consistently updated to reflect current findings both nationally and locally;

Through training and other communication strands practitioners are encouraged to maintain and increase their professional curiosity and respectful uncertainty when working with children and their families.