Office for Standards in Education (Ofsted)
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Serious case reviews: lessons being learnt but more still to do

Ofsted’s latest evaluation of 173 serious case reviews (SCRs) has found that local areas are learning lessons from cases when a child dies or is seriously injured as a result of abuse or neglect – 23% of reviews are judged good and 43% adequate. However, weaknesses still exist with over a third of reviews (34%) judged as inadequate. Even more needs to be done to ensure the review process improves the way children are protected from harm across the country.

Learning lessons from serious case reviews: year 2 published today, has found evidence to suggest that Local Safeguarding Children Boards (LSCBs) are taking a more robust approach in carrying out their SCRs to support the learning of lessons from these tragic incidents and improve their practice. Reviews are being carried out in a greater number of cases and by a larger number of Local Safeguarding Children Boards. These reviews are being carried out more quickly and with greater levels of independence, and the backlog of historic cases is largely now addressed. In addition there is evidence that LSCBs are co-operating more readily where a review spans more than one area.

The findings show that several weaknesses in practice identified in the previous report remain across the various groups. Instances of weak management and lack of joint working within and across agencies remain in some areas. Other examples of weak practice include failure to focus on the needs of the child, insufficient staff expertise, not making adequate risk assessments, and poor identification of ethnic or social cultural issues.

Christine Gilbert, Her Majesty’s Chief Inspector, said: 'Serious case reviews have a vital part to play in the protection of children. There are encouraging signs of improvement identified in this report. Agencies and local authorities are looking more rigorously at their processes and practices to learn lessons from tragic incidents. Learning these lessons will help protect more children from harm. However, much more work needs to be done to address the remaining weaknesses and to ensure that lessons lead to improved outcomes for children and young people. It is of great concern that over a third of reviews are still judged inadequate.'

The 173 serious case reviews carried out and completed between 1 April 2008 and 31 March 2009, relate to 219 children and include 113 cases of child deaths as a result of an incident. Of the 219 children identified, 68% were known to social care services at the time of the incident.

The number of SCRs in this report is larger than in Ofsted’s previous report as a result of an increase in the number of reviews carried out and a greater number of LSCBs initiating reviews. In addition many reviews were carried out more speedily and the report covers a full year of evaluations.

There are some encouraging signs that LSCBs are using lessons from SCRs to improve local practice. For example, one LSCB in the north west carried out a domestic violence audit as a result of a review. This revealed a lack of clarity about thresholds for referrals. As a result, the local authority developed an effective domestic violence project, wherein a specialist team now assesses all domestic violence referrals and puts together safety plans with children and carers. This has resulted in much earlier intervention to prevent harm to children.

Her Majesty’s Chief Inspector concludes: “'The report provides examples of good practice and I hope local authorities and other agency professionals will find these useful when conducting their own reviews or implementing an action plan for improvement.

'We all have a duty to protect children from harm. It is crucial that those involved in child protection use the serious case review process to deliver change and improvement.'

Notes for Editors

1. Learning lessons from serious case reviews: year 2 can be found at

2. Learning lessons from serious case reviews: year 2 is the second evaluation report of serious case reviews carried out and completed between 1 April 2008 and 31 March 2009. It follows on from Learning lessons, taking action: Ofsted’s evaluations of series case reviews 1 April 2007 to 31 March 2008.

3. 219 children were involved in 173 SCRs as some reviews deals with more than one child in a family.

4. The report Learning lessons from serious case reviews: year 2 covers a full year of evaluations, whereas in the previous report Learning lessons, taking action, the first SCR evaluation was completed in July 2007. This was due to the transfer of responsibility to Ofsted for inspection of children’s social services, taking effect in April 2007.

5. 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.

6. Government guidance (Working Together to Safeguard Children 2006) requires that where a child dies and abuse or neglect is known or suspected to be a factor, 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.

7. 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.

8. The Office for Standards in Education, Children's Services and Skills (Ofsted) regulates and inspects to achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children's social care, and inspects the Children and Family Court Advisory Support Service (Cafcass), schools, colleges, initial teacher training, work-based learning and skills training, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children’s services, and inspects services for looked after children, safeguarding and child protection.

9. Media can contact the Ofsted Press Office via Ofsted's enquiry line 08456 404040 between 8.30am - 6.30pm Monday - Friday. Out of these hours, during evenings and weekends, the duty press officer can be reached on 07919 057359

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