Safeguarding Practice Reviews (previously Serious Case Reviews)

The statutory guidance for Serious Child Safeguarding Reviews was updated in 2018, see:

Working Together to Safeguard Children 2018

Serious Child Safeguarding Practice Review Protocol Guidance

Also see Case Review Subgroup

“The purpose of reviews of serious child safeguarding cases, 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 and for the government and policy-makers…Reviews should seek to prevent or reduce the risk of recurrence of similar incidents” [Working Together 2018. Chapter 4]


Infant Injury

The East Sussex Safeguarding Children Partnership (ESSCP) undertook two Serious Case Reviews (SCR) in 2019, both featuring infant injury. To avoid delay in the dissemination of the learning from these SCRs, due to criminal investigations, the ESSCP has developed the ESSCP – Infant Injury Learning Briefing – 2020 on infant injury. Whilst not containing specific details, it will set out the headline learning from both these reviews.

This second ESSCP – Infant Injury Learning Briefing II (2021) includes learning from three further cases that were reviewed by the ESSCP, but which did not meet the criteria for conducting a local child safeguarding practice review (LSCPR). The briefing also captures emerging learning from a national review on infant injury.


East Sussex Safeguarding Children Partnership – ESSCP – published Serious Case Reviews:

East Sussex Safeguarding Children Partnership – Child W Serious Case Review Report

Date of Publication: 23 June 2021

The SCR was conducted following the death of an eight-week old baby, known as Child W, who died from non-accidental injuries in September 2018.


East Sussex LSCB SCR – Child T – Overview Report

East Sussex LSCB Child T SCR – Learning Briefing

SAB/ESSCP Joint Child T Learning Briefing

Date of Publication: 25 June 2019

The East Sussex Safeguarding Children Board agreed to undertake a Serious Case Review (SCR) in respect of a young man to be known as Child T. They recognised the potential that lessons could be learned from this case about the way that agencies work together to safeguard children and vulnerable young adults in East Sussex. Child T died in hospital aged 18 years and 6 months. His death was associated with his type 1 diabetes which he had developed as a child.


East Sussex LSCB SCR – Child S – Overview Report

East Sussex LSCB Family S SCR – Learning Briefing – 2018

Date of Publication: 13 March 2018

The SCR concerns two children aged 7 years and 22 months who experienced hidden neglect. The children were living in home conditions that were deemed unfit for human habitation when discovered. The mother had successfully kept all professionals, and wider family members away from the home. In addition the older child was found to have a significant physical impairment which had not been addressed and therefore means there will be a need for lifelong medical treatment.


East Sussex LSCB SCR – Child M – Overview Report

Date of Publication: 28th November 2016

The SCR concerns the services provided for a child who is referred to as Child M. Child M was aged 17 in March 2013 when she died as a result of a drug overdose taken while in the company of at least one adult. This was the last in a series of overdoses that Child M took which had resulted in hospital admission and serious health concerns from May 2011 onwards. Child M grew up in Surrey and lived there for the majority of her life. In September 2011, when she was 16 years old, Child M moved to East Sussex.


‘Thomas’ SCR (May 2016)

The East Sussex LSCB has contributed to a serious case review conducted by Tower Hamlets LSCB. There are no recommendations arising from the SCR specific to East Sussex LSCB or East Sussex County Council.


East Sussex LSCB SCR – Child P – Overview Report

Date of Publication: March 2016

The East Sussex LSCB have conducted a serious case review after the sad death of a young girl who was killed by her father, who then took his own life. The Overview Report concluded that this death could not have been prevented, nor could it have been predicted. Included in the Review are issues relating to Domestic Abuse, and the Action Plan that takes forward the learning from this Review, includes recommendations for improvements in the delivery of support relating to Domestic Abuse.


East Sussex LSCB SCR – Child K – Overview Report

Date of Publication: June 2015

This Serious Case Review was conducted by the East Sussex LSCB following the tragic death of a young baby. The person responsible for this is currently serving a prison sentence. The Overview Report concludes that this death was neither predictable nor preventable. There is an Action Plan to respond to the learning identified in this review, which will be monitored by the LSCB, in order to further improve services to very young children.


East Sussex LSCB SCR: Child H – Overview Report

Date of Publication: April 2014

The East Sussex LSCB decided to hold a serious case review because of the nature of this incident and the serious abuse it involved. Those responsible are now serving prison sentences and we are delighted to report that the young victim is thriving in a foster family. Based on the recommendations of this review, the LSCB has produced an action plan and is working with all the agencies involved to ensure those improvements are made.


East Sussex LSCB SCR: Child G – Overview Report

East Sussex LSCB SCR: Child G – Press Release

Date of Publication: December 2013

This Serious Case Review was completed by the East Sussex LSCB following the abduction of a teenager taken out of the country by their teacher in 2012. The teacher was subsequently convicted and imprisoned in 2013 for child abduction and child sexual offences.


Surrey LSCB SCR: Child J and Child K

Date of Publication: September 2013

This serious case review was carried out by Surrey LSCB as a result of the deaths of two children, Child J aged three and Child K aged two. Their mother was subsequently convicted of their murder. East Sussex LSCB participated in the review as the children were previously resident in East Sussex.


East Sussex LSCB SCR: Child DC & Child BC

Date of Publication: December 2011


National Serious Case Reviews

For a list of all National Serious Case Review Publications, please visit the

NSPCC National Repository of Case Reviews