A Guide to Significant Case Reviews

What is a Significant Case 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 – Significant Case Reviews are relevant to Scotland. Please select another region to find out about its type of inquiry: Northern Ireland, Wales and England.

Child abuse and neglect

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. Despite the recognition of the opportunities which 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. This is set out in ‘Working Together to Safeguard Children’ (2018).

Here we intend to help you 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.

Who is a child?

The National Guidance for Child Protection in Scotland (2014) defines a child as: ‘someone under the age of 18’. Children have the right, in both policy and legislation, to be protected from harm and abuse that could have lifelong consequences.

In 2017 the number of children on the child protection register in Scotland reduced by 3%from 2,715 in 2016 to 2,631. However, there is increased cause for concern relating to the rise in the emotional abuse of children. 

In 2017, 53% of children on the child protection register were under five, this is a notable increase since 2008. At case conferences, children on the register were found to be at an increased risk of serious abuse, as multiple concerns about their welfare were identified.

Although improvements in child protection is evident, there is more work to do to truly protect children from experiencing serious abuse and neglect. Here you will gain an insight into when SCRs are conducted, and how lessons learned from high-profile national cases have driven current child protection legislation and policy.

Child Protection Committees (CPCs)

Child Protection Committees (CPCs) exist in every area of Scotland. They were established in 1991 and aim to make sure every child and young person is safe and protected from any avoidable situations or acts of abuse and neglect.

CPCs are locally based, inter-agency strategic partnerships that have responsibility for developing, overseeing and evaluating child protection policy and practice across their locality.

They aim to protect the safety and welfare of children and young people by:

• Developing effective working partnerships between organisations and the community
• Providing child protection training and support to staff
• Developing child protection procedures for their local area by complying with the National Guidance for Child Protection in Scotland (2014)
• Raising awareness about the need to improve the safety of children and young people
• Implementing and following requirements set out in Getting it Right for Every Child (GIRFEC)

CPCs works with a range of agencies in each local authority. Members of the committee include the

• NHS
• Police
• Local Authority Departments: Children’s Services, Social Work, Criminal Justice, Education Services and Housing Services
• Scottish Children’s Reports Administration
• Voluntary sector for children and young people

Find your local Child Protection Committee.

Understanding Significant Case Reviews (SCR)

An SCRis a multi-agency process for establishing the facts and learning lessons from situations where a child has died or been significantly harmed. Child Protection Committees report findings from SCRs to the Child Protection National Leadership Group which supports learning and child protection policy development at a national level.

The aims and objectives of SCRs are to:

• Establish if there are lessons to be learned about how to improve child protection, to ensure they are able to access the support they need in the future.
• Learn where failures have occurred to improve services and recognise good practice.
• Make recommendations for action, if required, to support improvements.
• Consider how any findings, recommended actions and learning can be implemented to support effective action.
• Support accountability when things go wrong.
• Increase confidence in public sector services by identifying gaps in provision and developing action plans to resolve this
• Identify when cases may be appropriate on a national basis to extend learning and development.

When is an (SCR) conducted?

Significant Case Reviews take place when a case raises serious concerns about a professional or service involved. They are conducted by Child Protection Committees when a child has died and one or more of the following apply:

• Abuse or neglect is known, or suspected to have been involved
• The child, or a sibling was at any point in their life on the child protection register
• The death is by suicide or accident death
• The death is by alleged murder, culpable homicide, reckless conduct or act of violence
• At the time the of their death the child was in care

A SCR can also be conducted where a child has not died but has sustained significant harm or is at risk of significant harm, and the case gives serious concerns about professional or service involvement.

When a review is completed by the Child Protection Committee, they must decide whether to publish the whole report or an executive summary. Confidentiality must be adhered to, protecting the identities of people involved in the case.

Read a report about SCRs in Scotland.

Questions assisting effective SCRs

What happened? Overview of the case to establish the facts.

What could have been done to prevent abuse and/or neglect? What actions could’ve 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?

Child Protection National Leadership Group

The Child Protection National Leadership Group was established in 2017. The role of the group is to strengthen, support and improve child protection activity across Scotland.

It does this by:

• Identifying collaborative solutions by reviewing SCRs and advising on national recommendations for child protection systems
• Advising on national child protection policy and overseeing the current Child Protection Improvement Plan (CIP)in Scotland
• Reviewing arrangements for child protection across planning and service delivery
• Making links to emerging child protection issues and other relevant pieces of work
• Developing child protection policy
• Working in partnership with Child Protection Committees Scotland to support local areas to develop and deliver robust continuous improvement programmes.

Public Inquiries and Serious Case Reviews: Foundations for Change

There have been many public inquiries and serious case reviews in England 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.