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Serious Case Reviews

Important lessons are learned from the detailed review of cases where children have died or received a life-threatening injury due to abuse or neglect. Swindon LSCB conducts formal reviews of these and other serious child abuse cases in accordance with central government guidance contained in Working Together to Safeguard Children.

The Serious Case Review Sub-group oversees Serious Case Reviews (SCRs), with a membership of senior managers drawn from LSCB agencies.  Overview Panel members are identified according to the needs of each case to ensure that the panel is independent of involvement in the case and has access to any expert knowledge required.  The Chair of the Overview Panel and the author of the Overview Report are both independent of the LSCB.

Swindon LSCB Serious Case Review process​

Serious Case Reviews FAQ

Serious Case Reviews: Information for Families Leaflet

Learning from Serious Case Reviews 

Learning Leaflets for all Serious Case Reviews are published by the LSCB and can be found at

​​​Serious Case Reviews S & D

​​​​​Swindon LSCB is today (14th December 2016) publishing the reports on two Serious Case Reviews which were commissioned following the deaths of two babies in 2015 as a result of co-sleeping. The cases are not connected and occurred 6 months apart but the SCR process concluded at the same time. There are clearly similarities in that the babies died in similar circumstances with both Serious Case Reviews confirming that all professionals had provided clear safe sleeping advice to the families; however, both families were within the child protection system and it was felt by the LSCBs Case Review Group that there would be learning for organisations.

The key areas of learning from these two Serious Case Reviews have already been disseminated through partner agencies, discussed in workshops at the LSCBs Annual conference and fully integrated into the LSCB training programme.

The reports on both Serious Case Reviews and the Independent Chair’s statement can be downloaded from the following links:​

Swindon LSCB - SCR S & SCR D Statement

Swindon LSCB - SCR D

Swindon LSCB - SCR S

​​Serious Case Review reports are made available as PDFs on these pages for 12 months after the date of publication. After this time, please apply to the LSCB Team if you wish to access an archived executive summary.​

Contact: Simon Ratcliff, Swindon LSCB Strategic Manager

All SCRs are important, but some have reached a high level of national significance due to the severity of the cases.   These SCRs contain learning that extends beyond the areas where the tragic events took place and it is important the all LSCBs, agencies and practitioners are aware of them.

Thematic Review: Parents with a mental health problem, July 2015.  This thematic review was considered by the Swindon LSCB Case Review Sub Group in September 2015. This briefing is based on case reviews published since 2013, where the mental health problems of parents were a key factor. It pulls together and highlights the learning contained in the published reports.

Coventry SCR September 2013.  This Serious Case Review was completed by Coventry LSCB following the death of Daniel Pelka​.  His mother and stepfather were sentenced to a minimum of 30 years in prison after being convicted of his murder. 

Summary of the 'Lesson's Learnt'

East Sussex SCR 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 Jeremy Forrest in 2012. The teacher was subsequently convicted and imprisoned in 2013 for child abduction and child sexual offences.

North Somerset Serious Case Review In January 2012 North Somerset Safeguarding Board published an Overview Report and an Executive Summary of a Serious Case Review (SCR) conducted after the arrest of a teacher suspected of abusing children in his care.  Many will be familiar with the case which received significant media coverage  

When publishing the SCR Overview Report and Executive Summary the LSCB Chair recommended that the SCR was read by every head teacher, every chair of governors and safeguarding boards across the country because of the issues it raises and the recommendations it makes. The Parliamentary Under Secretary of State for Children and Families asked for the SCR to be brought to the attention of all LSCBs and DCSs to consider the implications for schools in their areas.

National Repository of Published Case Reviews

The national repository of published case reviews is a collaboration between the NSPCC and the Association of Independent LSCB Chairs. The aim is to hold all case reviews in a central location, so the learning contained within them is easier to access.

About the repository

Case reviews provide valuable lessons about how organisations are working together to safeguard and promote the welfare of children. However, despite organisational efforts to learn from serious cases, there is longstanding concern that the same issues are being identified again and again.

The NSPCC’s information service will continue to catalogue the published case reviews, including a summary and keywords. This allows reports to be retrieved by theme (e.g.. domestic abuse; parental mental health issues). The catalogue record will include either a link to the Local Safeguarding Children Board’s (LSCB) website, or a link to an electronic version stored within the library catalogue.

In addition, the NSPCC’s information service is developing a series of at-a-glance case review learning analyses focussed on recurring themes, such as parental substance misuse and domestic abuse. These analyses are intended as brief summaries of key learning written for practitioners presented in an easily digestible format.  To find out more, click here.

Swindon LSCB Learning and Improvement Framework

LSCBs are required under Working Together 2013 to maintain a Local Learning and Improvement Framework  which is shared across local organisations who work with children and families.  This framework sets out the type of case reviews and audits that the LSCB undertakes and collates learning from those reviews. 
Swindon LSCB has developed a Learning & Improvement Framework to enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result. This adheres to the principles established in Chapter 4 of Working Together 2015 and is designed to underpin and facilitate the development of a culture of continuous improvement across children's safeguarding in Swindon.