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Derby and Derbyshire Safeguarding Children Boards' Procedures Manual

Serious Case Reviews


Child Death Reviews Procedure


Working Together to Safeguard Children, Chapter 4: Improving Child Protection and Safeguarding Practice

Guide for the Police, CPS and LSCBs to assist with Liaison and Exchange of Information where there are simultaneous Serious Case Reviews and Criminal Proceedings (2014)

Please Note: Working Together to Safeguard Children – Following publication in July of the revised statutory guidance Working Together to Safeguard Children (2018), the Derby and Derbyshire Safeguarding Children Boards' Procedures will be reviewed by local partner agencies, and updated as required to reflect the new guidance. In the meantime these procedures continue to reflect practice locally and must be followed when responding to safeguarding concerns about a child. Under the Children and Social Work Act 2017, Serious Case Reviews will be replaced by new national and local arrangements for reviewing serious cases. LSCBs must continue to carry out all their statutory functions, including commissioning SCRs, until the point at which safeguarding partner arrangements begin to operate in a local area.

This chapter is currently under review.


  1. Introduction
  2. When Should the DSCB Undertake a Serious Case Review?
  3. Instigating a Serious Case Review
  4. Determining the Scope of the Review
  5. Timing
  6. Who Should Conduct Reviews?
  7. Agency Reviews
  8. The Overview Report
  9. The Family
  10. Feedback to Staff
  11. Disciplinary Processes
  12. Death in Custody
  13. Public Report
  14. DSCB Action on Receiving Reports
  15. Reviewing Institutional Abuse
  16. Accountability and Disclosure
  17. Further Information

1. Introduction

Derby and Derbyshire Safeguarding Children Boards (DSCBs) will follow the detailed guidance contained in Working Together to Safeguard Children, Serious Case Reviews.

Where a child dies or sustains a potentially life-threatening injury or serious or likely long term impairment and abuse or neglect are known or suspected Children's Social Care, in discussion with other agencies, should consider immediately whether there are other children at risk of harm who require safeguarding; For example siblings, or other children in an institution where abuse is alleged.

Serious Case Reviews (SCRs) are not inquiries into how a child died or who is culpable; that is a matter for Coroners and Criminal Courts respectively to determine, as appropriate.

2. When Should the DSCB Undertake a Serious Case Review?

The DSCB should always undertake a SCR when a child dies (including death by suicide), and abuse or neglect are known or suspected to be a factor in the child's death. This is irrespective of whether Children's Social Care is or has been involved with the child or family.

The criteria for undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned is set out in regulation 5(1)(e) Local Safeguarding Children Boards Regulations:

  1. For the purposes of paragraph (1) (e) a serious case is one where:
    1. Abuse or neglect of a child is known or suspected; and
    2. Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

"Seriously harmed" includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter-agency working, the LSCB must commission an SCR.

In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children's home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

Where more than one Local Safeguarding Children Board (LSCB) has knowledge of a child, the LSCB for the area in which the child is/was normally resident should take lead responsibility for conducting any review. The LSCB manager or Independent Chair will liaise directly with the relevant LSCB who are leading the review to ensure cooperation in the review process. Any other LSCBs that have an interest or involvement in the case should be included as partners in jointly planning and undertaking the review. In the case of Looked After Children, the responsible authority should exercise lead responsibility for conducting any review, again involving other LSCBs with an interest or involvement.

Any practitioner may refer such a case to the DSCB if it is believed that there are important lessons for inter-agency working to be learned from the case. In addition, the Secretary of State for the Department for Education has powers to demand an inquiry be held under the Inquiries Act 2005.

The following questions may help in deciding whether or not a case should be the subject of a SCR or a serious incident learning review (SILR) (sometimes called a management review) in circumstances other than when a child dies, the answer 'yes' to several of these questions is likely to indicate that a review could be considered:

  • Was there clear evidence that the child had suffered or was likely to suffer Significant Harm which was:
    • Not recognised by organisations or individuals in contact with the child or perpetrator; or
    • Not shared with others; or
    • Not acted upon appropriately?
  • Was the child abused in an institutional setting (for example, school, nursery, family centre, Young Offenders Institution, Secure Training Centre, Children's Home or Armed Services training establishment)?
  • Was the child abused while being Looked After by the local authority?
  • Does one or more agency or practitioner consider that its concerns were not taken sufficiently seriously, or acted upon appropriately, by another?
  • Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding children procedures, which go beyond the handling of this case?
  • Was the child subject of a Child Protection Plan or had previously been the subject of a plan?
  • Does the case appear to have implications for a range of agencies and/or practitioners?
  • Does the case suggest that the DSCB may need to change its local protocols or procedures, or that protocols and procedures are not being adequately circulated, understood or acted upon?

3. Instigating a Serious Case Review

DSCB should first consider whether or not a case should be the subject of a Serious Case Review (SCR), applying the criteria outlined above.

A Serious Case Review sub committee meeting should be called to consider whether a serious case review should take place.


In Derby the Serious Case Review Sub Group comprises of:

  • Independent Chair – Service Director Safeguarding and Disability Services, Children' Services, Derbyshire County Council;
  • Service Director – Early Intervention and Integrated Safeguarding, Children and Young People's Service, Derby City Council;
  • Head of Children's Quality Assurance, Children and Young People's Service, Derby City Council;
  • Designated Doctor - Southern Derbyshire Clinical Commissioning Group;
  • Designated Nurse - Southern Derbyshire Clinical Commissioning Group;
  • Detective Superintendent – Derbyshire Constabulary;
  • Representative Probation, National Probation Service (NPS);
  • Representative Probation, Community Rehabilitation Company (CRC);
  • Board Manager – Derby Safeguarding Children Board;
  • Legal advice to the SCR will be provided by the local authority Principal Solicitor;
  • Named Professional, Derbyshire Healthcare Foundation Trust;
  • Named Professional, Derby Teaching Hospitals Foundation Trust.

Other agencies join, dependent on nature of case.


In Derbyshire the Serious Case Review Sub-Committee comprises of:

  • Independent chair- Director of Specialist Services Children and Young People's Service, Derby City Council;
  • Assistant Director Early Help and Safeguarding Children's Services, Derbyshire County Council;
  • Head of Child Protection Children's Services, Derbyshire County Council;
  • Designated Doctor;
  • Designated Nurse;
  • National Probation Service;
  • Community Rehabilitation Company;
  • Detective Chief Inspector; Public Protection Unit, Derbyshire Police;
  • Principal Solicitor, Derbyshire County Council;
  • Education representative, Derbyshire County Council;
  • Board manager Derbyshire Safeguarding Children Board;
  • And others as appropriate.

In some cases, it may be appropriate to conduct individual or multi-agency management reviews, or a smaller-scale audit of individual cases which give rise to concern but which do not meet the criteria for a full serious case review. In such cases, arrangements should be made to share relevant findings with the SCR sub group/committee.

The Sub group/ committee's decision should be forwarded as a recommendation to the Chair of DSCB, who has ultimate responsibility for deciding whether or not to conduct a SCR.

Any practitioner may refer a case to DSCB if it is believed that there are important lessons for inter-agency working to be learned from the case.


The DSCB must notify Ofsted, DfE and the National Panel of Independent Experts within 5 working days of the Chair's decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and require the provision of further information on request and the DSCB chair may be asked to give evidence in person to the panel.

The DSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues.

4. Determining the Scope of the Review

The Review Panel should draw up clear terms of reference.

Relevant issues include:

  • What appear to be the most important issues to address in trying to learn from this specific case? How can the relevant information best be obtained and analysed?
  • The type of methodology used to carry out a review. The Child Practice Review model has been agreed as the preferred methodology for Serious Case Review (and included in the joint Learning Improvement Framework). Other methodologies may be used for either SCR or other reviews and these will be agreed as part of the terms of reference;
  • Over what time period should events be reviewed, that is how far back enquiries cover, and what should is the cut-off point? What significant events in the family history and/or background information will help better to understand the recent past and present?
  • Which organisations and practitioners should contribute to the review where appropriate including representatives from organisations not routinely involved in SCR processes, for example, the proprietor of independent school, playgroup leader, housing officers, and whether they should be asked to participate in person or to submit reports;
  • How should family members contribute to the review and who should be responsible for facilitating their involvement?
  • How should any public, family and media interest be managed, before, during, and after the review?
  • Does the LSCB need to obtain independent legal advice about any aspect of the proposed review?

5. Timing

Reviews will vary widely in their breadth and complexity, but in all cases, lessons should be learned and acted upon as quickly as possible.

Within one month of a case coming to the attention of the DSCB Chair, the decision should have been made by the Chair, following a recommendation from the Sub group/committee on whether a review should take place. Individual organisations should immediately secure case records, within 24 hours, to guard against loss or interference.

Reviews should be completed within six months. Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it emerges that a review cannot be completed within six months of the DSCB Chair's decision to initiate it, there should be a discussion to agree a timescale for completion.

In some cases, criminal proceedings may follow the death or serious injury of a child. Those co-ordinating the review should discuss with the relevant criminal justice agencies, at an early stage, how the review process should take account of such proceedings. This should include:

  • How this affects timing;
  • The way in which the review is conducted (including interviews of relevant personnel, considering that some staff may also be possible witnesses for the prosecution);
  • How to involve family members where possible even when suspects;
  • Its potential impact on criminal investigations; and
  • Who should contribute at what stage?
  • Disclosure issues.

SCRs should not be delayed as a matter of course because of outstanding criminal proceedings or an outstanding decision on whether or not to prosecute.

Much useful work to understand and learn from the features of the case can often proceed without risk of contamination of witnesses in criminal proceedings. In some cases it may not be possible to complete or to publish a review until after Coroner's or criminal proceedings have been concluded but this should not prevent early lessons learned from being implemented.

6. Who Should Conduct Reviews?

The initial scoping of the review should identify those who should contribute, although it may emerge, as information becomes available, that the involvement of others would be useful. In particular, information of relevance to the review may become available through criminal proceedings.

Depending on the SCR methodology used each relevant agency should be asked to review its involvement with the child and family, with a focus on the review's terms of reference and the identified time period. This should begin as soon as a decision is taken to proceed with a review, and even sooner if a case gives rise to concerns within the individual organisation.

Those conducting agency reviews of individual services should not have been directly concerned with the child or family, or the immediate line manager of the practitioner(s) involved. Designated professionals, in all agencies, will be responsible for liaising with neighbouring agencies outside Derby or Derbyshire, where these agencies have been involved with the subject child, to ensure that appropriate representation is made.

Relevant independent professionals (including GPs) should be asked and are expected to contribute.

Designated professionals should review and evaluate the practice of all involved health professionals and providers within the CCG area. This may involve reviewing the involvement of individual practitioners and Trusts and also advising named professionals and managers who are compiling reports for the review. Designated professionals have an important role in providing guidance on how to balance confidentiality and disclosure issues.

Where a Children's Guardian contributes to a review, the prior agreement of the courts should be sought so that the guardian's duty of confidentiality under the court rules can be waived to the degree necessary.

7. Agency Reviews

The scoping of a review will confirm the methodology to be used in agency reviews and whether summary reports, chronologies or fully detailed reviews are required.

In principle the aim of these reviews should be to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made, and if so, to identify how those changes will be brought about. Good practice should also be identified. The findings from the agency management review reports should be accepted by the senior officer in the organisation who has commissioned the report (if this is a different person) and should have been considered through individual agencies' own legal / information Governance departments before submission. Individual agencies will be responsible for ensuring that any recommendations for the agency are acted upon and that progress is reported into the relevant LSCB.

In addition, Derby / Derbyshire SCBs can require a person or body to comply with a request for information Section 14B of the Children Act 2004. This can only take place where the information is essential to carrying out SCB statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request.

8. The Overview Report

The review process will result in an overview report which brings together and analyses the findings of the various reports from organisations and others, and which makes recommendations for future action. Dependant on the SCR methodology used a practitioner learning event will also contribute to the learning contained within the overview report.

The reviewer/overview author should be a person who is independent of all the agencies/practitioners involved.

9. The Family

The family (that is those with Parental Responsibility) must be informed by DSCB that a SCR is being conducted, together with an explanation of the general purpose of a review at the earliest opportunity.

A decision should be made, and then regularly reviewed, by the Serious Case Review Panel as to the extent of involvement of the family in the review process. The family should be asked if they wish to contribute to the review and if so the process should be agreed by the review panel. Members of the wider family may also be involved in the process if that is believed by the review panel to be in the interests of the child.

The family should be consulted as to the extent to which and process by which the review is made public.

10. Feedback to Staff

Upon completion of each agency review report, there should be a process for feedback and de-briefing for staff involved. In addition, dependant on the methodology in use for the review, practitioners may be directly involved in a learning event to inform the review. There may also be a need for a follow-up feedback session if the overview report raises new issues for the organisation and staff members.

11. Disciplinary Processes

SCRs are not a part of any disciplinary enquiry or process, but information that emerges in the course of reviews may indicate that disciplinary action should be taken under established procedures. Alternatively, reviews may be conducted concurrently with disciplinary action. In some cases (for example, alleged institutional abuse) disciplinary action may be needed urgently to safeguard and promote the welfare of other children.

12. Death in Custody

Where a child dies in a custodial setting (prison, young offender institution or secure training centre) the Prisons and Probation Ombudsman investigates and reports on the circumstances surrounding the death of that child. The investigation examines the child's period in custody, including an assessment of the clinical care they received. The report would normally be made available to assist any serious case review process.

13. Public Report

In all cases there shall be an executive summary and overview report which are made public. Both the executive summary and the overview report should be anonymised and not contain identifying details. The exact timing and nature of the public reports will be agreed by DSCB according to the context of each individual case.

14. DSCB Action on Receiving Reports

On receiving an overview report DSCB should:

  • Ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report;
  • Translate recommendations into an action plan which should be signed up to at a senior level by each of the organisations that need to be involved;
  • The plan should set out who will do what, by when, and with what intended outcome, and what evidence is required to provide assurance that actions are completed. The plan should set out by what means improvements in practice/systems will be monitored and reviewed;
  • Clarify to whom the report, or any part of it, should be made available;
  • Disseminate the report of key findings to interested parties as agreed;
  • Make arrangements to provide feedback and de-briefing to staff, family members of the subject child, and the media, as appropriate;
  • Provide a copy of the overview report, executive summary action plan to the Department for Education, Ofsted and the National Panel of Independent Experts at least one week before publication;
  • The overview report should be anonymised and identifying details removed, prior to publication.
N.B. Ofsted will ask for overview reports, action plans and evidence of learning at the start of an unannounced inspection of arrangements to protect children.

15. Reviewing Institutional Abuse

See also Investigating Complex (Organised or Multiple) Abuse Procedure.

When serious abuse takes place in an institution, or multiple abusers are involved, the same principles of review apply but reviews are likely to be more complex, on a larger scale, and may require more time. Terms of reference need to be carefully constructed to explore the issues relevant to the specific case. For example, if children had been abused in a residential school, it would be important to explore whether and how the school had taken steps to create a safe environment for children, and to respond to specific concerns raised.

There needs to be clarity over the interface between the different processes of investigation (including criminal investigations); case management, including help for abused children and immediate measures to ensure that other children are safe; and review, i.e. learning lessons from the case to reduce the chance of such events happening again. The three different processes should inform each other. Any proposals for review should be agreed with those leading criminal investigations, to make sure that they do not prejudice possible criminal proceedings.

16. Accountability and Disclosure

The DSCB should consider carefully who might have an interest in reviews, for example, elected and appointed members of authorities, staff, members of the child's family, the public, the media - and what information should be made available to each of these interests. There are difficult interests to balance, among them:

  • The need to maintain confidentiality in respect of personal information contained within reports on the child, family members and others;
  • The accountability of public services and the importance of maintaining public confidence in the process of internal review;
  • The need to secure full and open participation from the different agencies and practitioners involved;
  • The responsibility to provide relevant information to those with a legitimate interest;
  • Constraints on public information sharing when criminal proceedings are outstanding, in that providing access to information may not be within the control of the DSCB.

It is important to anticipate requests for information and plan in advance how they should be met. A communication strategy is useful to ensure publication and other sharing of information is handled appropriately.

The publication of the overview report and executive summary will need to be timed in accordance with the conclusion of any related court proceedings. The content will need to be suitably anonymised in order to protect the confidentiality of relevant family members and others. DSCB should ensure the Department for Education are fully briefed in advance about the publication of the documents.

17. Further Information

NSPCC Serious Case Reviews Repository.

Serious Case Review Quality Markers - Supporting Dialogue about the Principles of Good Practice and how to Achieve Them (NSPCC / SCIE, 2016)