Safeguarding Practice Reviews (previously Serious Case Reviews)
A Local Child Safeguarding Practice Review (LCSPR) is a locally conducted multi-agency review in circumstances where a child has been abused or neglected, resulting in serious harm or death, and/or there is cause for concern as to the way in which agencies have worked together to safeguard the child.
The purpose of a review is to establish whether there are lessons to be learned about the way in which local professionals and agencies work together to safeguard children; identify what needs to be changed and, as a consequence, improve inter-agency working to better safeguard and promote the welfare of children.
The statutory guidance for Serious Child Safeguarding Reviews was updated in 2018, see Working Together to Safeguard Children 2018. Previously, these types of reviews were called Serious Case Reviews (SCRs).
When the ESSCP is notified of a serious safeguarding incident the ESSCP Case Review Group will ask agencies involved with the child to undertake a ‘rapid review‘ of the case.
The ESSCP has published the below learning briefings for cases where the decision was made not to undertake a child safeguarding practice review.
East Sussex Safeguarding Children Partnership published LCSPRs/SCRs:
This serious case review was commissioned following a serious safeguarding incident involving an infant, in 2018. The ESSCP published the ESSCP – Infant Injury Learning Briefing – 2020 to share learning from the review. Following the conclusion of the criminal investigation and court proceedings it is now possible to publish the above final report. Given the time between the safeguarding incident and publication of the report, the ESSCP has also published an addendum which highlights the impact of the learning on local practice.
The ESSCP commissioned this Local Safeguarding Practice Review following a serious incident involving the neglect of a large group of siblings. The ESSCP has published the above executive summary to protect the wellbeing of the children in the family. The ESSCP – Family CC LCSPR and NEGLECT Learning Briefing – 2022 FINAL sets out the headline learning from this review. This briefing also reflects on learning from two rapid reviews in 2022 which also feature learning on neglect.
The ESSCP undertook a LCSPR in 2021 regarding Child AA. Child AA was 17 years old when they were stabbed and as a result will require long term medication. The ESSCP – Child AA LCSPR Learning Briefing (September 2022) sets out the headline learning from this review.
The ESSCP undertook a LCSPR in 2021 in response to two serious safeguarding incidents with similar themes of domestic abuse, poor parental and child mental health, substance misuse, and sporadic engagement with services over a considerable period of time. The ESSCP – Thematic LCSPR Learning Briefing (September 2022) sets out the headline learning from this review.
The ESSCP undertook a LCSPR in 2021 regarding Child Z. Child Z was 18 months old when he died of a non-accidental head injury. The publication of the Child Z report is delayed due to criminal procedures. To ensure that learning is shared as soon as possible this ESSCP – Child Z LCSPR Learning Briefing (August 2022) sets out the headline learning from this review.
The ESSCP undertook a LCSPR in 2021 following the death of Child X. The tertiary hospital, where the child had been treated and subsequently died, had concerns about abuse and neglect. However, during the review process the ESSCP and Independent Reviewer did not find evidence to support these concerns. To protect the wellbeing of child X’s sibling/s, the ESSCP has published the report anonymously. Whilst not containing specific details of the case, this ESSCP – Child X Learning Briefing – 2022-updatedDec2022 sets out the headline learning from this review.
The ESSCP undertook a LCSPR in 2021 regarding Child Y. This was the case of a primary school aged child who attempted to take their own life at the family home. Sixteen months earlier they had made allegations that a family member had sexually abused them. To protect the wellbeing of Child Y, the ESSCP has published the report anonymously. Whilst not containing specific details of the case, this ESSCP Child Y LCSPR learning briefing (April 2022) sets out the headline learning from this review.
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.
To avoid delay in the dissemination of the learning from this SCRs (and another, Child V, due to criminal investigations), the ESSCP published the ESSCP – Infant Injury Learning Briefing – 2020 on infant injury.
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.
Safeguarding Adult Reviews
The East Sussex Safeguarding Adult Board commissioned a Safeguarding Adult Review (SAR) in 2022 to explore the circumstances that led to the death of an 18-year-old, who is referred to in this review as ‘Charlie’. While the SAB led the review, given Charlie’s age and significant involvement with a range of children’s services prior to their death, the ESSCP has published ESSCP – SAR Charlie Learning Briefing – 2023 – FINAL to highlight the learning that is relevant for services working with children and families.
Serious Case Review Archive
National Serious Case Reviews
For a list of all national LCSPRs and Serious Case Review Publications, please visit the NSPCC National Repository of Case Reviews