When a child dies or is seriously harmed as a result of abuse or neglect, a review may be conducted to identify ways that professionals and organisations can improve the way they work together to safeguard children and prevent similar incidents from occurring.
Each UK nation has its own terminology and guidance for carrying out and sharing the learning from the reviews. Cases that meet the criteria set out in the relevant guidance are reviewed by multi-agency panels.
The reviews are known as:
- child safeguarding practice reviews in England
- case management reviews in Northern Ireland
- learning reviews in Scotland
- child practice reviews in Wales.
In England, the local authority must notify the Child Safeguarding Practice Review Panel if:
- a child has died or been seriously harmed
- and abuse or neglect of the child is known or suspected.
This may include cases where a child has caused serious harm to someone else.
Serious harm includes, but is not limited to, serious and/or long-term impairment of a child’s mental or physical health or intellectual, emotional, social or behavioural development. This should include cases where impairment is likely to be long-term, even if this is not immediately certain.
Local safeguarding partners (local authorities, chief officers of police, and integrated care boards) must carry out a rapid review into all incidents notified to the Panel.
A copy of the rapid review should be sent to the Child Safeguarding Practice Review Panel along with notification of whether the local safeguarding partners will be carrying out a local child safeguarding practice review (previously known as a serious case review).
The local safeguarding partners may decide not to undertake a local child safeguarding practice review because they have already carried out several reviews concerning the same issue, so new learning is unlikely.
If a case is particularly complex or of national importance, the Child Safeguarding Practice Review Panel may decide to commission a national child safeguarding practice review.
In England, the key guidance for safeguarding practice reviews is Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (Department for Education, 2018).
Carrying out a child safeguarding review
Local authorities must notify the Child Safeguarding Practice Review Panel and relevant safeguarding partners within five working days if they know or suspect that a child has been seriously harmed or died because of abuse or neglect.
The Secretary of State and Ofsted must also be notified if a looked after child has died, whether or not abuse or neglect is known or suspected.
The Department for Education (DfE) has published guidance on how local authorities should notify incidents to the Child Safeguarding Practice Review Panel.
Local safeguarding partners must then undertake a rapid review within 15 working days. The rapid review should:
- assemble the facts of the case
- establish any immediate action needed to ensure a child's safety
- consider the potential for practice learning
- decide what steps they should take next, including whether a child safeguarding practice review should be commissioned.
As soon as a rapid review is complete, the safeguarding partners should send a copy to the Panel.
If the safeguarding partners determine that the issues raised by a case are of local importance, they may also commission a local child safeguarding review. They must inform the Panel, Ofsted and DfE that they are conducting a review, and share the name of the commissioned reviewer.
Once the Panel receives the rapid review they must determine, based on the complexity or national importance of the case, whether to commission a national child safeguarding practice review. If the decision is made to proceed with a national review, the Panel will agree the scope and methodology with the local safeguarding partners and engage with them and others involved in the case.
The Panel may also decide to commission a thematic national review, bringing together learning around a specific topic from a number of different incidents.
All child safeguarding practice reviews should:
- reflect the child's perspective and the family context
- be proportionate to the circumstances of the case
- focus on potential learning
- establish and explain the reasons why the events occurred as they did
- include a brief overview of the key circumstances, background and context of the case
- provide a summary of why relevant decisions by professionals were taken
- critique how agencies worked together and identify any shortcomings
- consider whether any shortcomings are features of practice in general
- consider what would need to be done differently to prevent harm occurring to a child in similar circumstances
- provide recommendations for what needs to happen to ensure that agencies learn from this case
(Child Safeguarding Practice Review Panel, 2019).
Reports should be published no later than six months after the date of the decision to carry out a review.
Safeguarding partners must publish local reviews and the Panel must publish national reviews unless they consider it inappropriate to do so. If the full report is not published there may still be information about improvements for best practice that are appropriate to publish.
Safeguarding partners should set out the justification for any decision not to publish details of a review.
The safeguarding partners should ensure that the way reports are written avoids harming the welfare of any children or vulnerable adults involved in the case. This may include removing intimate personal details of a family’s life.
- Local child safeguarding practice review reports must be publicly available for at least one year.
- The reports of national reviews must be made publicly available for at least three years.