When must Calderdale SCB consider conducting a serious case review?
Local Safeguarding Children Boards are required to consider holding a serious case review when a child dies and abuse or neglect is known or suspected to be a factor in the death. In addition, Local Safeguarding Children Boards should always consider whether a serious case review should be conducted 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.
What is the purpose of a
serious case review?
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.
Where can I find guidance
about serious case reviews?
Chapter 8 of
Working Together to Safeguard Children, 2006
contains detailed guidance regarding serious case
reviews and the processes involved.
The Calderdale Safeguarding
Children Board Procedures for serious case reviews
can be accessed here.
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.
How can agencies and
individual staff learn the lessons of serious case
reviews?
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
Analysing child deaths and serious injury through
abuse and neglect: what can we learn? A biennial
analysis of serious case reviews 2003-2005
Calderdale Serious Case
Review Executive Summaries
Click here to
see current summaries
There are three summary review reports published on
the Safeguarding Board website. 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 (2006).
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.
R. M. Stow
Independent Chair
Calderdale Safeguarding Children Board
Serious Case Reviews - Executive Summaries
