Serious Case Reviews

Serious Case Reviews (SCRs) are multi-agency reviews of how professionals and organisations have worked together with a child and their family when a serious incident has occurred. This serious incident can be the death of or serious harm to a child.

Regulation 5 of the Local Safeguarding Children Boards (LSCBs) Regulations 2006 sets out the functions of LSCBs which includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely:

5(1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

(2) 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.

Cases which meet one of these criteria (i.e. regulation 5(2) (a) and (b) (i) or 5 (2) (a) and (b) (ii) above) must always trigger an SCR. In addition, 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, or where the child was detained under the Mental Health Act 2005. 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 it is clear that there are no concerns about inter-agency working, the LSCB must commission an SCR. The final decision on whether to conduct the SCR rests with the LSCB Chair. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review.

The SSCB procedures for undertaking serious case reviews can be found at www.sunderlandscb.com. Please see attached SSCB information for further details.

Learning and Improvement Framework

Chapter 4 of Working Together to Safeguard Children and Young People 2015 requires LSCBs to have a local Learning and Improvement Framework (see Local Publications section of this website for a copy of Sunderland’s Learning and Improvement Framework) embedded across local organisations who work with children and their families. This Framework should enable organisations to be clear about their responsibilities, to learn from experience and improve services for children, young people, and their families as a result.

Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children. (see SSCB Learning and Improvement Framework in Local Publications for more information.)

Publication of Reports

All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. Final SCR reports should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted
The SCR’s published 2010 to date are provided below:
Name of Summary Date of Publication
SSCB Response to Thematic Report - Teenagers 13/09/16
Thematic Report - Teenagers 13/09/16
Young Person K Executive Summary 13/09/16
Young Person I Executive Summary 13/09/16
SSCB Response to Thematic Report - Babies 06/09/16
Thematic Report - Babies 06/09/16
Baby W and Child Z Serious Case Review 06/09/16
Baby O Serious Case Review 06/09/16
Baby E Serious Case Review 06/09/16
Consolidated Impact Statements - Babies 06/09/16
Baby Penny Serious Case Review 26/11/15
Baby N Serious Case Review 26/11/15
Baby L Serious Case Review 19/05/15
Baby A and Child C Serious Case Review 25/11/14
Baby A and Child C - 'Why' Questions Report (Core Assets) 25/11/14
Baby A and Child C, Sunderland Children's Services Progress Report/Single Agency Action Plan 25/11/14
Child D - Executive Summary 20/07/10
Child X - Executive Summary 15/06/11