Serious Case Reviews

The purpose of a serious case review is to:

• Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguarding and promote the welfare of children;
• Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; and
• As a consequence, improve inter-agency working and better safeguard and promote the welfare of children.

Serious case reviews are not inquiries into how a child died, or who is culpable. that is a matter for Coroners and criminal courts, to determine as appropriate.

Chapter 4 of Working Together to Safeguard Children, 2013 contains detailed guidance regarding serious case reviews and the processes involved.

You can also view the Calderdale (West Yorkshire) Safeguarding Children Board Procedures for serious case reviews.

Calderdale SCB has a serious case review monitoring sub-group which ensures that procedures and arrangements for undertaking serious case reviews are in place and complied with, and also monitors the progress of agency action plans which are intended to ensure that the recommendations for serious case reviews are implemented.

Calderdale Safeguarding Children Board will normally publish an anonymised executive summary of each serious case review, unless to do so is prejudicial to civil or criminal processes. These executive summaries will appear at the bottom of this page.

The government collates information from all serious case reviews undertaken within England and Wales, and produces a report every two years which draws out the main themes and lessons from the reviews.

- Improving safeguarding practice - Study of serious case reviews 2001-2003 (PDF)

- Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 (PDF)

There are three summary review reports published below. The incidents under review occurred in 2007. Two of these published in March 2009 relate to the deaths of young children by natural causes (Child A; Child B). The reviews have established that the deaths of the two children are not as a result of agency failings.

The death of a child is a life changing experience for the family and friends. The sympathies and condolences of everyone are for the families whose lives have changed forever as a result of their loss.

The third review (published 18/12/2009) relates to a child (Child C) who was seriously injured and whose parents have been convicted in relation to the injuries.

Why in the circumstances of the first two published reports, where a child's death is not from abuse or neglect, is a Serious Case Review undertaken?

There are a number of reasons why a SCR should be undertaken. At the time of each child's death there were a number of agencies working to support the family in relation to the care of their children.

In the circumstances it was decided that a review should be undertaken in order to explore whether any lessons emerge from the way in which agencies worked together and then if any improvements can be made to agency practice.

All of the Reviews were conducted in accordance with the national guidance in Working Together to Safeguard Children (2013).

The reviews were undertaken by Independent persons with extensive experience of child care services.

Although it was the first incident requiring that a Review should be undertaken the publication of the third review was protracted. This has been primarily as a result of the need to defer completion of the analysis and the writing of the final report until after the conclusion of the Criminal proceedings after which the parents were interviewed and the final report prepared. This was accepted by the Safeguarding Board and subsequently has been evaluated by OFSTED as is the National practice.

The Executive Summaries are published in accordance with the National guidelines.

The Reviews identified a number of recommendations. It is unsurprising given the close proximity of the events in 2007 that there are a number of parallel issues emerging from the reviews. These are included in the summary reports. These will lead to improvements in practice.