Learning from Reviews

The purpose of case reviews, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving. Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account.

SCSP has a Quality Assurance Framework (QAF) in place which illustrates how the Partnership's quality assurance and review activity generates learning which is delivered to those who work or volunteer with children and families. View the SCSP Quality Assurance Framework here.

A Brief Guide to Statutory Reviews: A new guide, published by the Vulnerability Knowledge and Practice Programme, provides additional information on various types of safeguarding reviews.

Child Safeguarding Practice Reviews (CSPR)

Child Safeguarding Practice Reviews are about promoting and sharing information about improvements, both within the area and potentially beyond, so Sheffield Safeguarding Children Partnership will publish reports, unless there are exceptional circumstances which make it inappropriate to do so. In these cases, the SCSP will publish information about the improvements that should be made following the review. Published reports or information will be available on this website for at least one year.

Case Reviews

Will be added when available.

Published briefings

Will be added when available

Learning from Rapid Reviews

Serious incident notifications (SINs) are made by local authorities to the Child Safeguarding Practice Review Panel and Department for Education when:

  • a child has died or been seriously harmed and
  • abuse or neglect of a child is known or suspected.

This may include cases where a child has caused serious harm to someone else.

Serious harm includes, but is not limited to, serious and/or long-term impairment of a child’s mental or physical health or intellectual, emotional, social or behavioural development. This should include cases where impairment is likely to be long-term, even if this is not immediately certain.

Local safeguarding partners must carry out a rapid review into all incidents notified to the National Panel.

A rapid review is required within 15 days of a notified serious incident. Professionals are asked to complete an audit and chronology of their service’s involvement with the child/ any family members. A multi-agency meeting is then held to:

  • Gather facts about the case, as far as can be established at the time.
  • Establish any immediate action needed to ensure a child's safety
  • Identify learning to safeguard and promote the welfare of children.

The Rapid review meeting makes the following decisions:

  • Are there issues identified that are of national significance? Is a national review considered to be necessary following the rapid review? If so, why?
  • Are there sufficient and sound reasons to proceed with an LCSPR? If it is decided to proceed with an LCSPR, an appropriate scope should be specified, with some identified key lines of enquiry.
  • Does the review identify relevant good practice, and should this be disseminated across the system?
  • Has the review identified clear agency and partnership actions to take forward, especially where there is no LCSPR recommended?

The three statutory partners then decide as to whether they agree with this recommendation or not.  A report is then submitted to the National Panel, and they will respond in writing whether they agree with the recommendations.

The panel will also determine, based on the complexity or national importance of the case, whether to commission a national child safeguarding practice review or whether to commission a thematic national review, bringing together learning around a specific topic from a number of different incidents.

Learning Resources

'Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. Safeguarding partners and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.'

This page has been designed to help all front-line practitioners and managers to gain a greater awareness of the identified learning topics and to support, guide and signpost to more local and national resources and multi-agency training.

Intro to Learning Lessons Reviews to be added

Learning from Multi Agency Audit Group (MAAG) Reviews

The Multi-Agency Audit Group (MAAG) sits within the Learning and Practice Improvement Framework of the SCSP. Its purpose is to support the Partnership’s statutory function in monitoring and evaluating the effectiveness of single and multi-agency safeguarding processes.

When a case is selected for multi-agency audit, the process requires each agency involved with the individual to complete an audit and brief chronology. Following this, agencies meet to discuss the case, including the effectiveness of partnership working.

The purpose of the MAAG is not to apportion blame on an individual or a service. The purpose is to highlight areas of strengths and good practice for both single agencies and in partnership working, areas requiring improvement, areas of identified learning and emerging themes, to enable a culture of continuous learning and improvement.

Best practice and learning points will be disseminated by all panel members within their own organisations and a record of each agency’s actions will be taken and carried forward until completed. Following the meeting, the SCSP publish a Learning Brief, which will be shared across agencies and can be accessed below

MAAG Briefings

Learning from National Reviews

The Child Safeguarding Practice Review Panel is an independent panel commissioning reviews of serious child safeguarding cases. They want national and local reviews to focus on improving learning, professional practice and outcomes for children.

The panel meets regularly to decide whether to commission national reviews of child safeguarding cases that are notified to it. The panel’s decisions are based on the possibility of identifying improvements from cases which it views as complex or of national importance.

The panel is responsible for:

  • Supervising reviews they commission.
  • Ensuring they are of a satisfactory quality.
  • Ensuring reports are completed within a suitable timeframe.
  • Identifying improvements that should be made by safeguarding partners.

The panel has its own statutory powers and is independent of the government and can make its own decisions. The statutory guidance on ‘Working together to safeguard children’ sets out how the panel operates and works with safeguarding partnerships.

Research and analysis from the Child Safeguarding Practice Review Panel:

  • Safeguarding children with disabilities in residential settings

Safeguarding children with disabilities in residential settings review sets out recommendations and findings for national government and local safeguarding partners to protect children at risk of serious harm.

The phase 1 report examines allegations of abuse and neglect of children living in three private residential settings located in Doncaster and operated by the Hesley Group.
The phase 2 report sets out recommendations to improve the safety, support and outcomes for children with disabilities and complex health needs living in residential settings.

  • Safeguarding children in elective home education

This review  explores common themes and patterns identified across reviews and highlights practice issues raised by safeguarding partners from across England. 

  • National review into child sexual abuse within the family environment

The National Review into Child Sexual Abuse Within the Family Environment "I wanted them all to notice" sets out recommendations and findings for national government and local safeguarding partners to protect children at risk.

The National Review analysed 136 serious child safeguarding incidents, and 41 related serious case reviews (SCRs) and local child safeguarding practice reviews (LCSPRs). It explores the specific challenges which feature in the identification, assessment, and response to child sexual abuse within the family environment.

  • Child Safeguarding Practice Review Panel Annual Report 2023 to 2024

The focus of this report is on serious incidents where children have died or suffered serious harm. It seeks to understand the patterns in practice that can be discerned through analysis of the 330 rapid reviews with incidents falling between April 2023 and March 2024, and 82 Local Child Safeguarding Practice Reviews considered by the Panel in this same period. Importantly, careful analysis of multi-agency practice when things have gone so catastrophically wrong in children’s lives can shed light on the experiences of the broader group of children who need safeguarding.

  • “It’s Silent”: Race, racism and safeguarding children

The Child Safeguarding Practice Review Panel report focused on 53 children from Black, Asian and Mixed Heritage backgrounds who died or were seriously harmed between January 2022 and March 2024. These children were subject to horrific abuse, including sexual abuse, fatal assault and neglect, with 27 children dying as a result. The report sought to understand the specific safeguarding needs of children from these specific ethnic backgrounds and how agencies helped to protect them before it was too late. It has revealed a significant silence in talking about race and racism in child safeguarding, with many local areas failing to acknowledge the impact of race, ethnicity and culture.

NSPCC National Case Review Repository

 

The NSPCC repository provides a single place for published case reviews to make it easier to access and share learning at a local, regional and national level. Access to the electronic versions of the case review reports stored by the NSPCC is available by accessing the NSPCC website library.

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