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3.2 Serious Case Review Process


Serious Case Reviews, Working Together to Safeguard Children

DfE Serious Case Review Quality Markers


Learning and Improvement Framework

Child Death Review Processes


In August 2016, a link was added to DfE Serious Case Reviews Quality Markers.


  1. Criteria
  2. Operational Procedure
  3. Methodology for Learning and Improvement

    Appendix 1: Serious Case Reviews Flowchart

1. Criteria

Newcastle Safeguarding Children Board (NSCB) must undertake reviews of serious cases in specified circumstances.

 1.1 Criteria for Notifiable Incidents

  • A notifiable incident is an incident involving the care of a child which meets any of the following criteria:
  • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;
  • A child has been seriously harmed and abuse or neglect is known or suspected;
  • A looked after child has died (including cases where abuse or neglect is not known or suspected); or
  • A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

The local authority should report any incident that meets the above criteria to Ofsted and the relevant LSCB or LSCBs promptly, and within five working days of becoming aware that the incident has occurred.

For the avoidance of doubt, if an incident meets the criteria for a Serious Case Review (see below) then it will also meet the criteria for a notifiable incident (above). There will, however, be notifiable incidents that do not proceed through to Serious Case Review.

1.2 Criteria for Serious Case Reviews

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This 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.

“Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. 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 there is definitive evidence that there are no concerns about inter-agency working, the LSCB must commission an SCR.

In addition, even if one of the criteria is not met, 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. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005. (Working Together to Safeguard Children).

2. Operational Procedure

The procedure must be read having had regard to the Child Death Review Processes, which incorporates the serious incident notification process (see Notification of serious childcare incident, Ofsted). Any professional can refer a case for consideration for a Serious Case Review where a child has died or been seriously harmed and they have concerns about the way that agencies have worked together to safeguard and promote their welfare; this includes the North of Tyne Child Death Overview Panel. The referral should be made in writing to the Chair (see Who's Who, Newcastle SCB) of NSCB, Case Review Committee (CRC), and copied to the NSCB Co-ordinator, who will notify the Independent Chair and the Assistant Director of Children’s Social Care. The Independent Chair and the Assistant Director of Children’s Social Care will ensure that the Director of Well-being, Care and Learning and the Chief Executive of Newcastle City Council are briefed and kept up to date with subsequent developments and decisions. 

Arrangements will then be made for the CRC to consider the circumstances of the case.

2.1 Decisions Whether to Initiate a Serious Case Review

The CRC will consider the circumstances of the case referred to them and agree whether it thinks it meets the criteria for a Serious Case Review; this will be made within 28 days of the serious incident notification to Ofsted. The Committee Chair will send the recommendation to the Chair of NSCB, with whom the final decision rests, who may seek advice and peer challenge from another Local Safeguarding Children Board (LSCB) Chair when considering their decision.

The NSCB Coordinator will notify Ofsted and the Department for Education of the decision; NSCB Independent Chair will advise the National Panel of Independent Experts within five working days of the Chair's decision. The Independent Chair and the Assistant Director of Children’s Social Care will ensure that the Director of Well-being, Care and Learning and the Chief Executive of Newcastle City Council are aware of the decision.   

A decision not to initiate a Serious Case Review may be subject to scrutiny by the national panel and may require the provision of further information on request; the LSCB chair may be asked to give evidence in person to the Panel.

The LSCB Chair should be confident that such a review will thoroughly, independently and openly investigate the issues. The LSCB will also want to review instances of good practice and consider how these can be shared and embedded. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. 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 Chair of the CRC will provide written feedback to the referrer on the outcome of the multi-agency discussion and the rationale for the decision. The Co-ordinator will keep NSCB Chair and the Assistant Director of Children’s Social Care informed throughout the process.

2.2 National Panel of Independent Experts on Serious Case Reviews

The NSCB Chair and the CRC should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: the decision by NSCB chair not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports and decisions not to publish.

They will comply with requests from the Panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

In cases where NSCB Chair has decided NOT to initiate a SCR, the Independent Chair will:

  • Inform the panel within 14 days and provide a copy of the local authority’s Serious Incident Notification (or if this is not available then brief anonyms details of the case covering the nature of the incident etc.);
  • Provide an explanation as to why the case does not meet the SCR criteria.

The Panel can be contacted via

2.3 Appointing Reviewers

NSCB CRC will appoint one or more suitable individuals to lead the Serious Case Review on its behalf. Such individuals should have demonstrated that they are qualified to conduct reviews using the Learning and Improvement Framework Procedure, Principles for a Culture of Continuous Improvement.

The lead reviewer will be independent of NSCB and the organisations involved in the case and will be expected to compile the final review report.

NSCB Chair will provide the National Panel of Independent Experts (see Section 2.3, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and consider carefully any advice which the Panel provides about the appointment/s.

Note: Working Together to Safeguard Children does not specify the need for an independent chair, or for a chair for the process: the need or not for this will depend on the individual choice of the LSCB and the review model selected.

2.4 Timescale for Serious Case Review Completion

NSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible for example because of criminal or related court proceedings, every effort will be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

2.5 Engagement of Organisations

NSCB CRC will ensure appropriate representation in the review process of professionals and organisations involved with the child and family and may decide as part of the Serious Case 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.

During the initial scoping stages the CRC will determine who will be involved in the process and how this will be done; this includes family members. Where there is an ongoing police investigation or any other parallel enquiry underway, the police and other relevant professionals will be consulted to ensure that these enquiries are not compromised.

Where a Serious Case Review is conducted in parallel with other reviews, for example Domestic Homicide Review, Safeguarding Adults Review, MAPPA Serious Case Review, Youth Justice Serious Incident Review, careful consideration will be given to ensure that the processes do not contradict or compromise each other. The lead reviewers in all processes will remain in regular contact with each other throughout.

The LSCB can require a person or body to comply with a request for information Section 14B of the Children Act 2004. This can only take place where the information is essential to carrying out LSCB statutory functions. Any request for information about individuals must be 'necessary' and 'proportionate' to the reasons for the request. LSCBs should be mindful of the burden of requests and should explain why the information is needed.

2.6 Agreeing Improvement Action

NSCB CRC will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions. They will monitor the “programme of action” on behalf of NSCB; this will involve monitoring any action plans and advising on the dissemination of lessons learned to frontline staff and NSCB partner organisations.

2.7 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the NSCB website. It will remain on the website for a minimum of 12 months and thereafter be available on request.

Publication of the review will be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or adults involved in the case. Consideration will also be given on how best to manage the impact of publication on those affected by the case. NSCB will comply with the Data Protection Act 2018 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report 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.

NSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

NSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If it is determined that the Review will not be published within 28 days of completion they will provide an expected date of publication to the Panel. If it is considered that a report will not be published at all, the NSCB Chair will inform the Panel which will provide advice and provide all relevant information to the panel on request, to inform its deliberations.

The NSCB Chair will inform the National Panel at any stage of the Serious Case Review if there are concerns about publication of the report and will provide the panel with the following information:

  • What has done to ensure that the Serious Case Review has been written with publication in mind;
  • Where any potential difficulties are coming from, for example from agencies involved in the review or from family members or concerns about media activity;
  • How NSCB has balanced the issues with the public interest in understanding the issues raised by the case and with the importance of ensuring that lessons are learned to improve services to children and families;
  • Whether there are any legal restrictions on releasing certain information in the report;
  • Whether consideration has been given to amending the style and content to make it fit for publication;
  • Whether NSCB has sought expert advice when considering publication, for example whether there has been advice sought from lawyers;
  • How NSCB is managing media interest in the case.

The NSCB Co-ordinator will advise the Association of Directors of Children’s Services at least 24 hours in advance of its publication.

3. Methodology for Learning and Improvement

Working Together to Safeguard Children does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it should consider the following five principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

If a Serious Case Review is initiated by NSCB discussions will be held in the initial scoping stages to determine which model or methodology will be used for that particular review based on the circumstances of the case itself.

Further Information

NSPCC Serious Case Reviews Repository

Appendix 1: Serious Case Reviews Flowchart

Click here to view Serious Case Reviews Flowchart.