Learning from Child Safeguarding Practice Reviews

Working Together to Safeguard Children 2018 (Chapter 4) introduced Child Safeguarding Practice Reviews to replace Serious Case Reviews as a method of reviewing serious child safeguarding cases.

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When do CSPRs take place?

CSPRs should take place if a child abuse or neglect is known, or suspected in a case and a child has died or a child has been seriously harmed and there is cause for concern about how the authority or other organisations or professionals worked together to safeguard the child.

Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area. They must commission and oversee the review of those cases, where they consider it appropriate for a review to be undertaken. In Wandsworth the responsibility for this rests with the Serious Cases Improvement and Learning (SCIL) Group.

Purpose

The purpose of these reviews at both local and national level is to identify improvements to be made to safeguard and promote the welfare of children. Learning is relevant locally, but it has a wider importance for all practitioners working with children and families. Reviews should seek to prevent or reduce the risk of recurrence of similar incidents.

Publication

During the transition period from Working Together to Safeguard Children 2015 (Chapter 4) there will be a number of outstanding Serious Case Reviews that will need to be completed under the 2015 statutory guidance. These will be completed and published in line with that guidance.

Working Together 2018 states:

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.

7 minute briefings

The purpose of 7 minute briefings is to provide a summary of the full Child Safeguarding Practice Reviews (formerly Serious Case Reviews) and identify what is expected to change as a result of the learning to try to prevent similar incidents from happening in the future. This is a technique borrowed from the FBI for its simplicity and ability to keep readers focused and not distracted by other issues. Research suggests that this is the ideal time span to concentrate and learning is more memorable. The 7 minute briefings will be a combination of information taken from the full SCR/CSPR and a reminder to think about ‘application to practice’. The structure will be the same to enable managers to become familiar with the format, The briefings do not have all the answers they are a tool to enable teams to reflect on their practice and systems. They should be delivered face to face to promote discussions and not included with other day to day issues to ensure impact. Please consider these 3 questions alongside the briefings:

  1. What are your key thoughts and reflections?
  2. How can we ensure the learning is embedded and how will we know this?
  3. How can we integrate the learning into team or service improvement plans?

Wandsworth CSPRs

Child A - published February 2020

In March 2018 Child A was admitted to the Paediatric Intensive Care Unit requiring interventions to stabilise his acute medical condition and to rebuild his weight. On 9 March 2018 a chest X-ray revealed a healing fracture of a rib. Neither parent had an explanation for this injury. Both parents had adverse childhood experiences.

Read full report and 7 minute briefing.

Georgina and Grace 

Georgina was brought to hospital in February 2018 by Ms G. Georgina was 10 months old and severely infected with Chicken Pox. A chest x-ray showed a healing rib fracture, further fractures were identified. All the injuries were suspected to be non-accidental.

Read Serious Case Review

Read 7 minute briefing

National CSPRs

Child C - Waltham Forest

Child C was a 14 year old boy who was murdered and had been criminally exploited. The review highlighted areas we are working to improve.

Read 7 minute briefing.

You can also read the full report and the board response on Waltham Forest Council's website - click on the tab for statutory reviews.

Tyrone Goodyear - Lewisham

This informative and interesting 7 minute briefing is from Lewisham SAB. Tyrone Goodyear was a 24 year old man who died in February 2019 following an overdose. This briefing touches on themes of housing, autism and safeguarding, and suicide. There is clear learning for CSC about the vulnerability of young adults with ASD which may mask other concerns.

Read 7 minute briefing

Learning from national CSPRs

The NSPCC provides series of at-a-glance briefings highlighting the learning from case reviews that are conducted when a child dies or is seriously injured, and abuse or neglect are suspected.

Each briefing focuses on a different topic, pulling together key risk factors and practice recommendations to help practitioners understand and act upon the learning from case reviews.

You can find these briefings on the NSPCC site

Complexity and Challenge: A triennial analysis of SCRs 2014 - 2017 (March 2020)

The context of complexity and challenge provides an underlying theme in this triennial review of a total of 368 SCRs (SCRs) from the period 1 April 2014 - 31 March 2017. As we looked into the reviews of children affected by serious and fatal child maltreatment over these three years, we were struck by the complexity of the lives of these children and families, and the challenges – at times quite overwhelming – faced by the practitioners seeking to support them in such complexity.

The study’s primary aim was to understand the key issues, themes and challenges from the cases examined and to draw out implications for both policy makers and practitioners. The process for learning from reviews is undergoing change and this analysis provides a timely opportunity to capture rich learning from these serious cases to inform the new local safeguarding arrangements outlined in Working Together to Safeguard Children 2018 (HM Government, 2018).

Child Safeguarding Practice Review Panel

Read the Child Safeguarding Practice Review Panel’s national review into sudden unexpected death in infancy (SUDI).

The review examined 14 incidents of SUDI from 12 local areas that were representative of the 40 SUDI cases reported to the Panel between June 2018 and August 2019.

This was a qualitative study, based on interviews with practitioners and families, underpinned by factual details from each case. The key findings combine evidence from casework visits with insights from wider research in relation to SUDI and its incidence in families where children are considered at risk of significant harm.Infants dying suddenly and unexpectedly represent one of the largest groups of cases notified to the Panel, with 40 notifications between June 2018 and August 2019. While these represent only a proportion of all SUDI, they occur in families who are particularly vulnerable and each one is a devastating loss for the family.

Guidance for the Rapid Review Process 2020

Rapid reviews are held to assist the Safeguarding Children Board/Partnership in deciding whether to convene a Serious Case Review or alternative learning review as per the new Working Together 2018. 

View full guidance for Rapid Review Process.

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