7.6 Serious child safeguarding incidents

Sometimes a child suffers a serious injury or death as a result of child abuse or neglect. Understanding not only what happened but also why things happened as they did can help to improve our response in the future. Understanding the impact that the actions of different organisations and agencies had on the child’s life, and on the lives of his or her family, and whether or not different approaches or actions may have resulted in a different outcome, is essential to improve our collective knowledge. (Working Together 2018)

Reviews of serious child safeguarding cases, at both local and national level, can identify improvements to be made to safeguard and promote the welfare of children.

Working Together 2018 introduced new statutory guidance on how lessons from serious child safeguarding incidents are learned. At a local level, the responsibility lies with the local safeguarding partners. At a national level, the responsibility lies with the Child Safeguarding Practice Review Panel.

Serious child safeguarding incidents are those in which:

  • abuse or neglect of a child is known or suspected and
  • the child has died or been seriously harmed.

Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health.


Child Safeguarding Practice Review Panel

Local authorities in England must notify the national Child Safeguarding Practice Review Panel (the panel) if they know or suspect a child has been abused or neglected, and the child dies or is seriously harms in the local authority area. They must also notify the panel is a child who is normally resident in the local authority areas dies or is seriously harmed outside England.

They should notify both the panel and the local safeguarding partners within five working days of becoming aware that the incident has occurred. They should also notify the Secretary of State and Ofsted where a child has died, whether or not abuse or neglect is known or suspected.

The panel will decide whether it is appropriate to commission a national review of the case, taking into account whether the case highlights improvements needed to safeguard the welfare of children; whether it raises issues requiring legislative change or changes to guidance; and whether it highlights recurrent safeguarding themes.

The panel will notify the local safeguarding partnership of their decision and communicate their rationale, including to families. If a national review is to be undertaken, they will discuss with the safeguarding partnership the potential scope and methodology.

Decisions on local and national reviews

The safeguarding partnership must decide whether the incident meets the criteria for local review. Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. Issues might appear to be the same in some child safeguarding cases but reasons for actions and behaviours may be different and so there may be different learning to be gained from similar cases. Decisions on whether to undertake reviews should be made transparently and the rationale communicated appropriately, including to families.

The criteria which the local safeguarding partners must take into account include whether the case:

  • highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified
  • highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children
  • highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children
  • is one which the Child Safeguarding Practice Review Panel have considered and concluded a local review may be more appropriate.

Safeguarding partners should also have regard to the following circumstances:

  • where the safeguarding partners have cause for concern about the actions of a single agency
  • where there has been no agency involvement and this gives the safeguarding partners cause for concern
  • where more than one local authority, police area or clinical commissioning group is involved, including in cases where families have moved around
  • where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings.

Rapid Reviews

The safeguarding partners should promptly undertake a rapid review of the case, in line with any guidance published by the Panel. The aim of this rapid review is to enable safeguarding partners to:

  • gather the facts about the case, as far as they can be readily established at the time
  • discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately
  • consider the potential for identifying improvements to safeguard and promote the welfare of children
  • decide what steps they should take next, including whether or not to undertake a child safeguarding practice review

As soon as the rapid review is complete, the safeguarding partners should send a copy to the Panel. They should also share with the Panel their decision about whether a local child safeguarding practice review is appropriate, or whether they think the case may raise issues which are complex or of national importance such that a national review may be appropriate. They may also do this if, during the course of a local child safeguarding practice review, new information comes to light which suggests that a national review may be appropriate.

As soon as they have determined that a local review will be carried out, they should inform the Panel, Ofsted and DfE, including the name of any reviewer they have commissioned.

Process of local reviews

The safeguarding partnership will commission a reviewer who has appropriate professional knowledge, understanding and practice, and the ability to recognise the complex circumstances in which practitioners work together to safeguard children.

The methodology used during a review should provide a way of looking at and analysing frontline practice, as well as organisational structures and learning. The methodology should be able to reach recommendations that will improve outcomes for children. All reviews should reflect the child’s perspective and the family context.

Engagement of organisations

The Safeguarding Partnership will ensure appropriate representation in the review process of professionals and organisations involved with the child and family, establish timescales for action to be taken, agree success criteria and assess the impact of the actions.

The review should be proportionate to the circumstances of the case, focus on potential learning, and establish and explain the reasons why the events occurred as they did.

The Safeguarding Partnership may decide as part of the Local Learning Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review.

In addition, the Safeguarding Partnership can require a person or body to comply with a request for information. This can only take place where the information is essential to carrying out the partnership’s statutory functions. Any request for information about individuals must be necessary and proportionate to the reasons for the request. Safeguarding Partnerships should be mindful of the burden of requests and should explain why the information is needed.

The safeguarding partners must supervise the review to ensure that the reviewer is making satisfactory progress and that the review is of satisfactory quality. The safeguarding partners may request information from the reviewer during the review to enable them to assess progress and quality; any such requests must be made in writing.

Safeguarding partners must ensure that the final report includes:

  • a summary of any recommended improvements to be made by persons in the area to safeguard and promote the welfare of children
  • an analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report.

Any recommendations should be clear on what is required of relevant agencies and others collectively and individually, and by when, and focused on improving outcomes for children.

Reviews are about promoting and sharing information about improvements, both within the area and potentially beyond, so safeguarding partners must publish the report, unless they consider it inappropriate to do so. In such a circumstance, they must publish any information about the improvements that should be made following the review that they consider it appropriate to publish. The name of the reviewer(s) should be included. Published reports or information must be publicly available for at least one year.

Safeguarding partners must send a copy of the full report to the Panel and to the Secretary of State no later than seven working days before the date of publication.

Depending on the nature and complexity of the case, the report should be completed and published as soon as possible and no later than six months from the date of the decision to initiate a review.

Further information

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