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Last updated: 03.12.19

A Guide to Child Safeguarding Practice Reviews

What is a Child Safeguarding Practice Review?

Throughout the UK, formal inquiries are carried out in order to understand and analyse cases where abuse or neglect is known or suspected and a child has died, or been seriously harmed. Each region has its own name for its local inquiries – Child Safeguarding Practice Reviews are relevant to England. Please select another region to find out about its type of inquiry: Northern Ireland, Wales and Scotland.

Child abuse and neglect

Children are defined in the Children Act 2004 and the Children and Social Work Act 2017 as any person aged under 18 years of age.

In 2018, the Department for Education (DfE) reported 53,790 children in the UK were being supported through a child protection plan, indicating the largest increase since 2014. Representing an 84% increase in child protection plans over the last decade (LGA, 2018) illustrating the need to improve child safeguarding practice and policy.

Reviews are required when children come to serious harm following abuse and neglect. Lord Laming (2009) stated reviews are an important tool for learning lessons, but despite the opportunities reviews provide to improve child safeguarding practice, child abuse is still occurring. 

In recognition of shortcomings in child protection, highlighted by the tragic deaths of Baby P, Victoria Climbié, Daniel Pelka, Holly Wells and Jessica Chapman, the government has developed new review protocols and guidance to provide an increasingly robust framework to reduce the risk of child abuse set out in ‘Working Together to Safeguard Children’ (2018).

Here we intend to help you to understand the foundations for current policy, whilst highlighting where child protection has failed, to enable you to support your professional curiosity and efficacy as a frontline practitioner.

History of Child Safeguarding Practice Reviews (SPRs)

Formal inquiries, which are used to examine, understand and respond to scandals, have been in existence since Victorian times. 

Serious Case Reviews (SCRs) were developed to go beyond simply describing what happened, and instead analyse and identify what went wrong with a view to identifying key actions for improvements in child safeguarding practice.

Chapter 4 of  ‘Working Together to Safeguard Children’ (DfE, 2010, 2013 and 2015) sets out the requirements for an SPR. Namely, they should be carried out for every case where abuse or neglect is known or suspected and either a child dies, or a child is seriously harmed and there are concerns about how organisations worked together to safeguard the child.

The Munro Review of Child Protection

The Munro Review of Child Protection (2011) is an independent review of the child protection systems in England and was completed by Professor Eileen Munro and commissioned by Michael Gove, who was the Secretary for Education at the time. Munro stressed the need for reviews to focus on the causation of serious child abuse, as opposed to blaming an individual or an organisation.

It highlighted the need for more analysis and identification of what went wrong in child abuse cases to establish clear actions for improvement. This has been a clear focus ofSCRs, which has provided the foundation for Safeguarding Practice Reviews (SPR). SPRs which first appeared in Chapter 4 of ‘Working Together to Safeguard Children’ (2018) reflecting updates to the Children Act 2004, Children Act 1989 by the Children and Social Work Act 2017.

Defining Child Safeguarding Practice Reviews (CSPRs)

Child Safeguarding Practice Reviews (CSPRs) are systematic reviews of serious child safeguarding cases, at both a local and national level.

They are undertaken at a local level by Local Safeguarding Children Partnerships (LSCPs), formerly Local Safeguarding Children Boards, LSCBs, and at a national level by the Child Safeguarding Practice Review Panel.

Serious child safeguarding cases are those in which abuse or neglect of a child is known or suspected, and the child has died or been seriously harmed.

Serious harm is considered to be serious immediate harm or injury and any longer-term impairments, covering physical, mental, intellectual, emotional, social and behavioural development.

Local Safeguarding Children Partnerships (LSCPs)

These partnerships consist of at least three safeguarding partners. Under the Children Act 2004 (amended by the Children and Safeguarding Act 2017), the local authority identifies the safeguarding partners as the local authority, the clinical commissioning group and the chief officer of police, though often partnerships will consist of other agencies and organisations who are considered essential to achieving effective child protection practice. Overall, safeguarding partnerships construct robust child protection procedures and systems in their areas to promote the safeguarding and welfare of every child in that area.

Local Child Safeguarding Practice Reviews (CSPR)

At a local level, the LSCP is responsible for identifying serious child safeguarding cases in its area and running the review of the case. The rationale for carrying out a review must be open and transparent, and guidance from the Child Safeguarding Practice Review Panel must be followed.

The Children Act 2004 (amended by the Children and Social Work Act 2017) requires local authorities in England who know, or suspect that a child has been abused or neglected, to notify the Child Safeguarding Practice Review Panel if:

  • The child dies or is seriously harmed in the local authority’s area, or
  • While normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

Function and aims of (CSPRs)

There are numerous functions and aims of the CSPRs. They aim to:

  • Examine how local professionals and organisations worked together to safeguard the child or young person
  • Consider what happened to lead the child, or young person to experience abuse or neglect
  • Assist organisations in improving safeguarding practice and policy to improve the effectiveness of child protection systems
  • Understand practice from the perspective of the individuals and organisations involved at the time
  • Focus on learning and improving practice, rather than hold individuals, organisations and agencies to account
  • Translate their findings into actions, which support and underpin sustainable change and improvement, in order to prevent or reduce the risk of recurrence of similar incidents.

National Child Safeguarding Practice Review Panel

The Panel has been funded by the DfE since June 2018, though it acts independently from government. It consists of eight members with diverse professional backgrounds and expertise in child protection and aims to look at how practice can be improved and what needs to be changed at a whole systems level. It can commission reviews of serious child safeguarding cases where they are complex and or in the national interest.

Questions asked by the Review Panel

  • What happened? Overview of the case to establish the facts.
  • What could have been done to prevent abuse and/or neglect? What actions could have been taken to stop the abuse from happening?
  • Is there typicality in the contextual factors and the responses of agencies? Are there similar challenges, or difficulties within agencies that could have contributed to the abuse and/or neglect?
  • What changes to the way in which agencies operate could help to prevent abuse/neglect? Identifying actions that could improve child safeguarding procedures to reduce the risk of harm to children and young people.
  • Have agencies changed their practices as a result of this learning? What changes in organisations have been made to support improvement in child safeguarding practice?

Read more about the Child Safeguarding Practice Review Panel.

Public Inquiries and Serious Case Reviews: Foundations for Change

Prior to the introduction of Child Safeguarding Practice Review Panel in 2018, public inquiries and high-profile serious case reviews predominantly placed child protection across the national domain.

There have been many public inquiries and serious case reviews highlighting areas for improvement and development in child safeguarding policies and practice.

Some high-profile child protection cases have been significant in driving change and improvement. Select each one for more information.

Public Inquiry:  Holly Wells and Jessica Chapman (Sir Michael Bichard, 2004)

Public Inquiry: Victoria Climbié (Lord Laming, 2003)

Serious Case Review: Baby P (2009)

Serious Case Review: Daniel Pelka (2013)

The NSPCC have put together a National Case review repository detailing cases from across the UK, you can access the repository here.

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