Office for Standards in Education (Ofsted)
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Urgent action needed to improve serious case review system

Ofsted is calling for urgent action to reform the serious case review system which was set up to ensure that lessons are learnt when a child dies or is seriously injured as a result of abuse or neglect.

Since its inception in April 2007, the children’s inspectorate Ofsted has evaluated 92 serious case reviews finding that more than a third (38) is inadequate. Today it publishes an in depth report into the lessons to be learnt from the first 50 of these reviews, conducted between 1 April 2007 and 31 March 2008.

Learning Lessons: Taking Action highlights that serious case reviews must be more child focused, must be prepared with greater urgency so that lessons can be learned more quickly, and that the reviewers must demonstrate greater independence. The report is highly critical of progress being made to protect society’s most vulnerable children. Serious case reviews are carried out by Local Safeguarding Children Boards following the death or serious injury of a child where abuse or neglect is known or suspected.

Commenting on the report findings, Her Majesty’s Chief Inspector of Education, Children's Services and Skills, Christine Gilbert, said: “This report and the latest figures available clearly show that many children’s services are failing to learn fast enough from the most serious cases of abuse and neglect. Too many opportunities are missed and too many vulnerable children are still being let down by the system designed to protect them.

”All involved in child protection need to look hard at their policies, processes and, most crucially, practices on the ground to better protect children. Those who come into regular contact with children, such as teachers and health visitors, must learn how to spot the danger signs. And action is needed to stop children falling through the gaps between agencies. This is not a new message – but one which must be heard and acted upon with real urgency.”

Of the 50 serious case reviews considered in the report, 20 were inadequate and none was outstanding.

Of the 50 children involved, around 35 were known to social care agencies. All of the children concerned had come into contact with ‘universal services’ – such as health, education and other professionals – but too often they missed the warning signs or failed to act.

The report points to continuing weaknesses in communication between agencies and poor understanding of basic child protection symptoms and risk factors. It highlights that in many cases no single agency has a complete picture of families and children at risk. And all too often standards of care that would not be acceptable in other families are accepted, allowing abuse or neglect to go unchecked.

Key findings of the report are that:

  • health, education and other professionals who come into contact with vulnerable children on an everyday basis need better training
  • serious case reviews need to focus much more closely on the children concerned – rather than the agencies involved
  • serious case reviews must be done quickly - some reviews have taken more than three years to complete; in one instance over four years - so lessons can be learnt and action taken
  • serious case reviews must be more independent
  • too often professionals took the word of parents at face value without focusing enough on the child.

The Chief Inspector added: “In this report we have included a comprehensive series of recommendations to guide Local Safeguarding Children Boards and the Department of Children, Schools and Families, as well as the agencies and professionals concerned.

“We know from our evidence that serious case reviews are generally successful at identifying what has happened to the children concerned – but are less effective at addressing why. More needs to be done to get underneath the headlines if we are to make the necessary improvements.

“The most important thing is that these recommendations are acted upon and that the lessons from our report – and recent tragic events – are learnt and embedded.”

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Notes for Editors

1. The report Learning Lessons: Taking Action can be found on the Ofsted website The serious case reviews evaluated in this report are listed in the appendix.

2. Ofsted has also published today a complete list of the serious case reviews by local authority that it has reviewed since 1 April 2007 and up until 31 August 2008. This list includes the grade awarded for each serious case review report. Of the 92 reports of serious case reviews evaluated, 20 were good and 34 were satisfactory. However, 38 were inadequate.

3. The law states that every children’s services authority must have a Local Safeguarding Children Board (LSCB). LSCBs exist to ensure that the council and its partners in each local area work together effectively to safeguard and promote the welfare of children in that locality. The LSCB’s role includes safeguarding and promoting the welfare of children.

4. Government guidance (Working Together to Safeguard Children 2006) requires that where a child dies and abuse or neglect is known or suspected, the Local Safeguarding Children Board (LSCB) must conduct a serious case review. LSCBs must also consider conducting a serious case review where:

  • a child sustains a potentially life-threatening injury or serious and permanent impairment to health and development through abuse or neglect
  • a child has been subject to particularly serious sexual abuse
  • a child’s parent has been murdered and a homicide review is being initiated
  • a child has been killed by a parent with a mental illness
  • the case gives rise to concerns about inter-agency working to protect children from harm.

5. The purpose of a serious case review is to:

  • establish whether there are any lessons to be learned from the case about inter-agency working
  • identify clearly what these lessons are, how they will be acted upon, and what is expected to change as a result
  • improve inter-agency working and better safeguard and promote the welfare of children.

6. The Office for Standards in Education, Children's Services and Skills (Ofsted) regulates and inspects registered childcare and children's social care, including adoption and fostering agencies, residential schools, family centres and homes for children. It also inspects all state maintained schools, non-association independent schools, pupil referral units, further education, initial teacher education, and publicly funded adult skills and employment based training, the Children and Family Courts Advisory Service (Cafcass), and the overall level of services for children in local authority areas (through annual performance assessments and joint area reviews).

7. The Ofsted Press Office can be contacted on 020 7421 6622 between 8.30am and 6.30pm Monday to Friday. During evenings and weekends the out-of-hours duty press officer can be reached on 07919 057 359. Alternatively you can email your enquiry to

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