‘Learning the Lessons’ from Child Deaths

From the 1st April 2008 it became a statutory function of Local Safeguarding Children Board’s to establish a Child Death Overview Panel to review all child deaths up to the age of 18 years. The role of the Child Death Overview Panel is to identify trends and patterns to prevent such deaths occurring in the future.

What is a Serious Case Review?

In a very small proportion of cases when a child is seriously injured or dies and abuse or neglect is known or suspected to be a factor an independent panel of experts are commissioned to carry out a Serious Case Review. The purpose of Serious Case Reviews is to:

• Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;
• Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and
• Improve intra- and inter-agency working and better safeguard and promote the welfare of children.

Serious Case Reviews are not inquiries into how a child died or was seriously harmed, or into who is culpable. These are matters for coroners and criminal courts, respectively, to determine as appropriate. Serious Case Reviews focus on improving practices that safeguard and promote the welfare of children.

Publication of Serious Case Reviews

The Birmingham Safeguarding Children Board in conjunction with Ofsted and the Department for Education closely monitor the quality and timeliness of the Serious Case Review process as defined in ‘Working Together to Safeguard Children’. Serious Case Reviews are subject to independent evaluation by Ofsted, once this process is finalised, Birmingham Safeguarding Children Board publish the findings on website.

From the 10th June 2010 there is a requirement for LSCB’s to publish anonymised Overview Reports together with the Executive Summary, unless there are compelling reasons relating to the welfare of any children directly concerned for this not to happen. These documents detail the key findings, emerging good practice and recommended action.

Please find below a link to the Executive Summaries and Action Plans for all Serious Case Reviews that have been finalised, evaluated and published by the Birmingham Safeguarding Children Board to date.

Published Serious Case Reviews in Birmingham

Serious Case Reviews - Other Local Safeguarding Children Board's

The Birmingham Safeguarding Children Board and its partner agencies have also contributed to Serious Case Reviews in other parts of the country. Please find below the link to the relevant Local Safeguarding Children Board websites to access more information on these Serious Case Reviews.

'Child Y' Serious Case Review Executive Summary
- Hosted by Leicestershire and Rutland LSCB relates to agencies in Staffordshire, West Midlands and Derbyshire.

Serious Case Review Executive Summary 6 (November 2010).
- Hosted by Coventry LSCB relates to agencies in Coventry, West Midlands and Solihull.

National Guidance - Learning Lessons from Serious Case Reviews
   

• Ages of concern: learning lessons from Serious Case Reviews (Oct 2011) - click here

• Serious and fatal child maltreatment 2009 - 2010 (October 2011) - click here
• A study of recommendations arising from Serious Case Reviews 2009 - 2010 (Sep 2011) - click here