Child Safeguarding Practice Reviews

Child protection in England is a complex multi-agency system with many different organisations and individuals playing their part. Reflecting on how well that system is working is critical in improving our response to children and their families.

Sometimes a child suffers a serious injury or death as a result of abuse or neglect. Understanding not only what happened but also why it happened can help improve our response in the future. Appreciating the impact that organisations and agencies had on the child’s life, and on the lives of their family members, and whether or not different approaches or those actions could have resulted in a different outcome, is essential. It is in this way that we can make good judgements about what might need to change at a local or national level.

The purpose of serious child safeguarding case reviews, at local and national level, is to identify improvements that can be made to safeguard and promote the welfare of children. Learning is relevant locally but has a wider importance for all practitioners working with children and families and for the government and policymakers. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.

Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations, or agencies to account, as there are other processes for that purpose, including employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside a review or at a later stage. Employers should consider whether any disciplinary action should be taken against practitioners whose conduct and/or practice falls below acceptable standards and should refer to their regulatory body as appropriate.

The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel (the panel) and at a local level with the safeguarding partners. The panel is responsible for identifying and overseeing the review of serious child safeguarding cases which, in its opinion, raise issues that are complex or of national importance. It should also oversee the system of national and local reviews and how effectively it is operating.

As outlined in chapter 2 of Working Together to Safeguard Children, the safeguarding partners play an integral role in establishing a system of learning and reflection locally. Safeguarding partners must:

• Identify and review serious child safeguarding cases which, in their opinion, raise issues of importance in relation to their area;
• Commission and oversee the review of those cases if they consider it appropriate.

The way in which this responsibility is divided between the lead safeguarding partners (LSPs) and their delegates is for local decision. Accountability for ensuring learning from serious incidents is implemented is the responsibility of the LSPs and the impact of local and national reviews should be evidenced in yearly reports and subjected to independent scrutiny.

The panel and safeguarding partners have a shared aim to identify improvements to practice for protecting children from harm and should maintain an open and ongoing dialogue. This will enable them to raise concerns, highlight commonly recurring areas needing further investigation (whether leading to a local or national review), and share learning, including from success, that could lead to improvements elsewhere.

As such, safeguarding partners should have regard to any guidance the panel publishes. Guidance will include the timescales for a rapid review (see Working Together to Safeguard Children, chapter 5, paragraphs 343-344) and for the panel’s response.

Serious child safeguarding cases are those in which:

• Abuse or neglect of a child is known or suspected;
• 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. This is not an exhaustive list. When making decisions, judgement should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred. Local authorities and safeguarding partners should refer to the Child Safeguarding Practice Review Panel Guidance for Safeguarding Partners for further clarity on issues relating to the criteria for serious child safeguarding cases.

The local authority should notify the panel of any incident that meets the above criteria via the Child Safeguarding Online Notification System. It should do so within five working days of becoming aware it has occurred. Though the responsibility to notify rests on the local authority, it is for all three safeguarding partners to agree which incidents should be notified in their local area. Where there is disagreement, the safeguarding partners should follow local dispute resolution processes.

The local authority must notify the Secretary of State for Education, and Ofsted of the death of a looked after child.

The local authority should also notify the Secretary of State for Education and Ofsted of the death of a care leaver up to and including the age of 24. Note - care leavers are entitled to support from their Personal Adviser up to their 25th birthday. Local authorities are required to keep in touch with all care leavers up the point they reach age 21, and to make their best efforts to contact all care leavers aged 21 to 24 annually to remind them that they remain eligible for support. If a young person chooses not to take up support between 21 to 24 years of age the local authority may no longer be aware of a care leaver’s whereabouts or circumstances (and therefore their death).

This should be notified via the Child Safeguarding Online Notification System. The death of a care leaver does not require a rapid review or local child safeguarding practice review. However, safeguarding partners must consider whether the criteria for a serious incident has been met and respond accordingly, in the event the deceased care leaver was under the age of 18. If local partners think that learning can be gained from the death of a looked after child or care leaver in circumstances where those criteria do not apply, they may wish to undertake a local child safeguarding practice review.

The local authority, on behalf of the safeguarding partners, has a duty to notify the panel about all serious incidents that meet the criteria. The number of serious incidents notified is not a reflection of local area performance. Making a notification will ensure that learning is identified and fed back into the system to prevent future harm or death. The link to the Child Safeguarding Online Notification form for local authorities to notify incidents to the panel is available on the Report a Serious Child Safeguarding Incident page on GOV.UK.

The Department for Education (DfE) is responsible for publishing annual serious incident data. This data is extracted from the notifications submitted by local authorities, so accuracy when completing the online notification form is key. All incidents meeting the criteria should be notified as “serious harm” or “death”, except where there is a clear reason to notify as “other”, for example, in cases where the notification relates to a perpetrator. A notification regarding the suicide of a child should be made where abuse or neglect is a factor.

Others who have functions relating to children should inform the safeguarding partners of any incident they think should be considered for a child safeguarding practice review.

Safeguarding partners must:

• Identify serious child safeguarding cases that raise issues of importance in relation to their area;
• Commission and oversee the review of those cases if they consider review appropriate.

When a serious incident becomes known to safeguarding partners, they must consider whether the case meets the criteria and guidance for a local review (Children Act 2004). If safeguarding partners determine that the criteria are met to undertake a local child safeguarding practice review, then a serious incident notification and rapid review must take place.

In some cases, a ‘serious child safeguarding case’ may not meet the criteria for a serious incident notification but may nevertheless raise issues of importance to the local area. That might, for example, include where there has been good practice, poor practice or where there have been ‘near-miss’ incidents. Safeguarding partners may choose to undertake a local child safeguarding practice review in these or other circumstances, in which case they should be clear about their rationale for undertaking such a review and what its focus will be.

It is for safeguarding partners to determine whether a review is appropriate, given that the purpose of a review is to identify improvements to practice. Meeting the criteria does not mean that safeguarding partners must automatically carry out a local child safeguarding practice review.

All incidents should be considered on a case-by-case basis using all information that is available to local safeguarding arrangements. Issues might appear to be the same in some cases, but reasons for actions and behaviours may differ resulting in useful learning for the local area.

Decisions on whether to undertake reviews should be made transparently and collaboratively between safeguarding partners, and the rationale recorded and communicated appropriately, including to families. Where there are disagreements, local dispute resolution processes should be followed.

Learning from local reviews should be reflected in the annual reports published yearly by the safeguarding partners.

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 review is to enable them to:

• Gather the facts about the case, as far as they can be readily established;
• Discuss whether any immediate action is 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 to undertake a child safeguarding practice review.

As soon as the rapid review is complete, the safeguarding partners should send a copy of their findings to the panel. The panel may share this with the DfE, if requested, to enable the DfE to carry out its functions. 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 that are complex or of national importance such that a national review may be appropriate. They may also do this if, during a local child safeguarding practice review, new information comes to light suggesting 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, providing the name of the reviewer they have commissioned.

On receipt of the information from the rapid review, the panel must decide whether it is appropriate to commission a national review of a case or cases. They must consider the criteria and guidance that follows:

The criteria the panel 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;
• Raises or may raise issues requiring legislative change or changes to guidance issued under or further to any enactment;
• Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children.

The panel should also have regard to:

• Circumstances where significant harm or death to a child educated otherwise than at school;
• Circumstances where a child is seriously harmed or dies while in the care of a local authority, or while on (or recently removed from) a child protection plan;
• Circumstances where the case may raise issues relating to safeguarding or promoting the welfare of children in institutional settings. This includes children’s homes (including secure children’s homes) and other settings with residential provision for children, custodial settings where a child is held (including police custody, young offender institutions and secure training centres), and all settings where detention of a child takes place, including under the Mental Health Act 1983 or the Mental Capacity Act 2005;
• Cases which involve a range of types of abuse.

As well as considering a notification from a local authority, information from a rapid review and local child safeguarding practice reviews, the panel should consider a range of other evidence, including inspection and other reports and research. The panel may also consider any other criteria it considers appropriate to identify whether a serious child safeguarding case raises issues that are complex or of national importance.

In many cases there will need to be dialogue between the safeguarding partners and the panel to support the decision-making process. The safeguarding partners must share further information with the panel if requested.

The panel should inform the relevant safeguarding partners promptly following receipt of the rapid review, if it considers that:

• A national review is appropriate, setting out the rationale for its decision and the next steps;
• Further information is required to support its decision-making, including whether the safeguarding partners have decided to commission a local review.

The panel should decide on whether to undertake a national review and communicate its rationale appropriately, including to families. The panel should notify the Secretary of State if it decides to carry out a national review.

On receipt of the information from a rapid review or following its appraisal of a number of rapid reviews that highlight a particular theme, the panel must decide whether it is appropriate to commission a national review of a case, or cases, or to undertake a thematic review. For the criteria and guidance that the panel considers in its decision- making, refer to the Child Safeguarding Practice Review Panel Guidance for Safeguarding Partners.

If the panel decides to undertake a national review, it should discuss with the safeguarding partners its potential scope and methodology and how they it will engage with them and those involved in the case.

There will be instances where a local review has been carried out which could then form part of a thematic review that the panel undertakes at a later date. There may be other instances where a local review has not been carried out but where the panel considers that the case could be helpful to a future national review. In such circumstances, the panel should engage with safeguarding partners to agree how the review should be conducted.

Alongside any national or local reviews, there could be a criminal investigation, a coroner’s investigation and/or professional body disciplinary procedures. The panel and the safeguarding partners should have in place clear processes for how they contribute to with other investigations (including a domestic homicide review, multi-agency public protection arrangements, or safeguarding adult’s reviews), and collaborate with those responsible for carrying them out. This will reduce the burdens on, and anxiety for, the children and families concerned as well as uncertainty and duplication of effort.

The safeguarding partners are responsible for commissioning and supervising reviewers for local reviews. Safeguarding partners may also consider appointing reviewers from the child safeguarding practice review panel pool of reviewers. 

In all cases they should consider whether the reviewer has:

• Professional knowledge, understanding and practice relevant to local child safeguarding practice reviews, including the ability to engage with practitioners, children, and families;
• Knowledge and understanding of research relevant to children’s safeguarding issues;
• Ability to recognise the complex circumstances in which practitioners work together to safeguard children;
• The ability to understand practice from the viewpoint of the individuals, organisations or agencies involved at the time rather than using hindsight;
• The ability to communicate findings effectively;
• Any real or perceived conflict of interest.

The safeguarding partners should agree with the reviewer the method by which the review should be conducted, taking into account this guidance and the principles of the systems methodology recommended by the Munro review. It should provide a way of looking at and analysing frontline practice as well as organisational structures and learning, and allow those involved in the review to reach recommendations that will improve outcomes for children. All reviews should reflect both the child’s perspective and the family context.

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

As part of their duty to ensure the review is of satisfactory quality, the safeguarding partners should ensure that:

• Practitioners are fully involved and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
• Families, including surviving children (in order that the child is at the centre of the process) are invited to contribute;
• Families understand how they are going to be involved and have their expectations appropriately and sensitively managed.

The safeguarding partners must supervise the review (to ensure the reviewer is making satisfactory progress and the review is of satisfactory quality. They may request information from the reviewer to enable them to assess this and any such requests must be made in writing. The President of the Family Division’s guidance covering the role of the judiciary in serious case reviews should also be noted in the context of child safeguarding practice reviews.

The safeguarding partners must ensure the final report includes:

• A summary of any recommended improvements to be made by individuals or organisations in the area to safeguard and promote the welfare of children;
• An analysis of any systemic or underlying reasons actions were taken or not taken in respect of matters covered by the report.

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

Reviews are about promoting and sharing information about improvements, both within the area and potentially beyond, so the safeguarding partners must publish the report, unless they consider it inappropriate to do so. Where the safeguarding partners decide, further to Section 16F(5) of the Children Act 2004, not to publish the report but only to publish information relating to improvements to be made, they must provide a copy of the report and the information to the Secretary of State and the Panel, no later than 7 days prior to the date of publication of that information. In such a circumstance, they must publish any information about the improvements that should be made following the review they consider appropriate to publish. The name of the reviewers should be included.

Published reports or information must be publicly available for at least one year.

When compiling and preparing to publish the report, the delegated safeguarding partners should consider carefully how best to manage the impact of the publication on children, family members, practitioners and others closely affected by the case. The safeguarding partners should ensure that reports are written in such a way so that what is published avoids harming the welfare of any children or vulnerable adults involved in the case.

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 (‘working day’ means any day which is not a Saturday, Sunday, or bank holiday)  before the date of publication. Where the safeguarding partners decide only to publish information relating to the improvements to be made following the review, they must also provide a copy of that information to the panel and the Secretary of State within the same timescale. They should also provide the report, or information about improvements, to Ofsted within the same timescale.

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. Where other proceedings may have an impact on or delay publication (for example, an ongoing criminal investigation, inquest or future prosecution) the safeguarding partners should inform the panel and the Secretary of State of the reasons for the delay. Safeguarding partners should also set out for the panel and the Secretary of State the justification for any decision not to publish either the full report or information relating to improvements. Safeguarding partners should have regard to any comments that the panel or the Secretary of State may make in respect of publication.

Every effort should also be made, both before the review and while it is in progress, to:

• Capture points from the case about improvements needed;
• Take corrective action and disseminate learning.

The safeguarding partners should take account of the findings from their own local reviews and from all national reviews, with a view to considering how identified improvements should be implemented locally, including the way in which organisations and agencies work together to safeguard and promote the welfare of children. The safeguarding partners should highlight findings from reviews with relevant parties locally and should regularly audit progress on the implementation of recommended improvements. Improvement should be sustained through regular monitoring and follow up of actions so that the findings from these reviews make a real impact on improving outcomes for children.

The panel must set up a pool of potential reviewers who can undertake national reviews, a list of whom must be publicly available. If they consider that there are no potential reviewers in the pool with availability or suitable experience to undertake the review, they may select a person who is not in the pool. When selecting a reviewer, the panel should consider whether they have any conflict of interest which could restrict their ability, or perceived ability, to identify improvements impartially.

For national child safeguarding practice reviews, the panel should follow the same guidance on procedure and supervision as for local child safeguarding practice reviews.

The panel must ensure that the final report includes:

• A summary of any improvements being recommended to the safeguarding partners and/or others to safeguard and promote the welfare of children;
• An analysis of any systemic or underlying reasons why actions were taken or not taken in respect of matters covered by the report.

The panel 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 should be included.

The panel should work with safeguarding partners to identify and manage the impact of the publication on children, family members, practitioners and others closely affected by the case.

The panel must ensure that reports or information published are publicly available for at least three years. The panel must send a copy of the full report to the Secretary of State no later than seven working days before the date of publication. Where the panel decides only to publish information relating to the improvements to be made following the review, they must also provide a copy of that information to the Secretary of State within the same timescale. The panel should also send a copy of the report or improvements to the relevant safeguarding partners, Ofsted, the Care Quality Commission and His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services.

Reports should be completed and published within six months of the date of the decision to initiate a review. Where other proceedings may have an impact on or delay publication, for example, an ongoing criminal investigation, inquest or future prosecution, the panel should advise the Secretary of State of the reasons for the delay. The panel should also set out for the Secretary of State the explanation for any decision not to publish either the full report or information relating to improvements. During the review, the panel should share any points that arise about improvements needed with the safeguarding partners in any local authority areas covered by the review and others as applicable.

The panel should send copies of published reports of national and local child safeguarding practice reviews or published information relating to improvements that should be made following those reviews, to Foundations (What Works Centre for Children and Families) and relevant inspectorates, bodies, or individuals as they see fit. Where a local review results in findings which are of national importance, or in recommendations for national government, the panel should consider the potential of those recommendations to improve systems to safeguard and promote the welfare of children and how best to disseminate and embed such learning.

Serious incident notification

All serious child safeguarding incidents must be notified to the panel.

Notifications should be sent within five working days of the local authority becoming aware of the incident.

Notifications are made through the online notification system, which is accessible 24 hours a day.

The rapid review

Rapid reviews should be submitted to the panel within 15 working days of the incident. This is a non-statutory requirement and more details can be found in the Child Safeguarding Practice Review Panel Guidance for Safeguarding Partners.

Rapid reviews should be submitted to the panel secretariat, at Mailbox.NationalReviewPanel@education.gov.uk.

Local child safeguarding practice review

Full reports must be sent to the panel and the Secretary of State for Education no later than seven working days before the date of publication.

Final reports, information relating to improvements to be made following a review, and reasons for any delay, should be notified to Mailbox.NationalReviewPanel@education.gov.uk and Mailbox.CPOD@education.gov.uk

In addition, final reports and information about improvements should also be sent to Ofsted SCR.SIN@ofsted.gov.uk

Working Together to Safeguard Children: Statutory Guidance 

Report a serious child safeguarding incident: guidance for Local Authorities

Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018

Children Act 2004 Section 16F - Local Child Safeguarding Practice Reviews

Child Safeguarding Practice Review Panel Guidance for Safeguarding Partners

Child Safeguarding Practice Review Panel - Child Safeguarding Rapid Review Examples

Child Safeguarding Practice Review Panel - Guidance and Regulation

Child Safeguarding Practice Review Panel - National Safeguarding Practice Reviews

Child Safeguarding Practice Review Panel – Annual Reports

Research and Analysis of Serious Case Reviews - Department for Education