Serious Case Reviews

Reviews are always undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death.  Additionally a serious case review is always considered where:

and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.  This includes inter-agency and/or inter-disciplinary working.

A serious case review is a formal process of bringing together the records of all agencies that have had involvement with the child and family.  An overview report is produced which provides a complete picture of events. This report contains analysis of contact with the child and family and decision making, it draws conclusions and makes recommendations. 

Ofsted publications
Ofsted is the inspection and regulatory body that, until 2012, evaluated all serious case reviews.  
Learning Lessons from Serious Case Reviews 2009-2010 provides analysis of 147 serious case reviews completed between 1 April 2009 and 31 March 2010.
The Voice of the Child - Learning Lessons from Serious Case Reviews - this report provides an analysis of 67 serious case reviews that Ofsted evaluated between 1 April and 30 September 2010. The main focus of the report is on the importance of listening to the voice of the child.  A summary report is also available.

DfE publications
New Learning from Serious Case Reviews (July 2012) - the sixth two-yearly report covers the period 1 April 2009 to 31 March 2011.  It includes a number of new insights alongside recurring messages for practice.

Sharing information and learning from Kirklees case reviews 

The KSCB flowchart 'How we learn from Serious Case Reviews' shows how agencies act on recommendations and the quality assurance process undertaken by the Board to ensure that required changes are embedded in practice. 

Learning lessons and bringing about improvements in practice are key aims of the review process. One of the ways in which the Safeguarding Children Board shares information about case reviews is through publication of the Overview Report, Executive Summary Report and Action Plan.  

All enquiries should be directed to the Kirklees Council Press Officer - 01484 221835

After twelve months reports from serious case reviews are removed from the website.  They can be requested from the Safeguarding Children Board.  Please ring 01484 225019, or email

NSPCC Publications

The NSPCC has established a national repository of published case reviews. Access to this aims to improve learning and help professionals to protect children.

The NSPCC also provide thematic briefings that focus on specific topics, pulling together the key risk factors and practice recommendations.

Framework for Undertaking Serious Case Reviews

To view the framework click here - Updated March 2017

Learning From Serious Case reviews

KSCB has produced summaries of recent serious case reviews to support the dissemination and embedding of learning that has arisen from these reviews. The summaries are 2 sides of A4 and include a summary of the case, key themes and lessons for practitioners and managers as well as links to supporting guidance documents.

Kirklees Learning Document SCR 024 
Kirklees Learning Document SCR 025
Board response to SCR 025
Kirklees Learning Document SCR 026
Kirklees Learning Document SCR 027

Learning Lessons Review 3
Board Response to LLR3

Practice Reviews

Practice reviews may be carried out where learning has been identified which has presented opportunities for multi-agency practice to be improved. Practice reviews are also a means of sharing skills and experience where interventions have been especially successful and where outcomes for children are known to have been significantly improved.    

Summary reports of Practice Reviews carried out in Kirklees in the last twelve months are listed below.

Good Practice Review carried out in respect of parents whose substance abuse led to child protection concerns; and the successful
interventions by agencies to support a change in parenting resulting in significantly improved outcomes for children.

KSCB Good Practice Review Report - May 2013 

CAMHS Report - A Child's Journey

This report is a full review of all the impact of emotional wellbeing and mental health services provided in Kirklees for children and young people on safeguarding children and promoting their welfare. To view the report, click here.

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