SERIOUS CASE REVIEWS

When a child dies, and abuse or neglect are known or suspected to be a factor in the death, the LSCB should always conduct a serious case review as set out in Working Together to Safeguard Children. This should look at the involvement with the child and family of organisations and professionals to consider whether there are any lessons to be learned about the ways in which they work together to safeguard and promote the welfare of children. Additionally, LSCBs should always consider whether a serious case review should be conducted in other circumstances where:

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

Once it is known that a case is being considered for review, each organisation should secure records relating to the case to guard against loss or interference and produce an Individual Management Review (IMR). The aim of the IMR is 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.

Once the IMRs have been completed by each individual agency the LSCB will commission an overview report that brings together and analyses the findings of the various reports from organisations and others, and that makes recommendations for future action. This will be carried out by an independent panel, whose members will be identified according to the needs of each case to ensure that they are independent of any involvement in the case and have access to any expert knowledge required.

Following a serious case review, an action plan should be drawn up and implemented and arrangements made to provide feedback and debriefing to staff, family members of the subject child and the media as appropriate. An Executive Summary of the overview report will be published.

Local SCR Executive Summaries

SCR Executive Summary - Child 1 2009

SCR Executive Summary - Child D 2010

National Child Abuse Inquiries

Lord Laming has called for a step-change in leadership and practice to help protect children from harm. His far-reaching report, The protection of children in England: A progress report, was commissioned by the Children's Secretary Ed Balls in November 2008 and looks at children's services across England. It was published on 12 March 2009 and can be viewed on the Every Child Matters website using the above link.

The Bichard Inquiry report (2004)

Sir Michael Bichard’s enquiry into child protection procedures in Humberside Police and Cambridgeshire Constabulary in the light of the trial and conviction of Ian Huntley for the murder of Jessica Chapman and Holly Wells.

The Victoria Climbie Inquiry report (2003)

The full report of Lord Laming's inquiry into the circumstances surrounding the death of Victoria Climbie.

Victoria Climbie - key findings from the self audits of NHS organisations, social services departments and police forces (2003)

Joint Chief Inspectors Report on the key findings from the self audits of NHS organisations, social services departments and police forces.