4.6 Explain how serious case reviews inform practice

This guide will help you answer 4.6 Explain how serious case reviews inform practice.

A Serious Case Review, often called an SCR, is a process carried out after a child suffers serious harm or death and abuse or neglect is suspected. The review is arranged by the local safeguarding partnership. In the past this would have been the Local Safeguarding Children Board (LSCB), but now it is led by safeguarding partners in the local authority, health and police.

An SCR is not meant to blame individual workers. Its aim is to find out what went wrong and what lessons can be learned. It looks at the work of agencies involved and asks whether anything could have been done differently to protect the child. The findings then influence future practice.

When an SCR Takes Place

SCRs take place in certain circumstances, for example:

• When a child has died and abuse or neglect is known or suspected
• When a child has been seriously harmed and there are concerns about how professionals worked together
• When a case suggests that lessons about safeguarding need to be shared

The decision to start a review is taken by safeguarding partners. This happens after an initial assessment of the case. The review must be done quickly but thoroughly so that recommendations can be acted on without delay.

Purpose of Serious Case Reviews

The main purposes are:

• To understand what happened
• To analyse how agencies worked together
• To identify patterns of poor practice, gaps in knowledge, or communication problems
• To inform and shape training and policies
• To prevent similar incidents in the future

An SCR looks at whether policies and procedures were followed, and whether those procedures were effective.

How an SCR is Carried Out

The process can involve:

• Collecting documents such as case notes, records, and reports
• Interviews with staff from different agencies including schools, social work, health, and police
• Looking at training records to see if staff were educated in safeguarding procedures
• Analysing timelines of events and decision making

The process is structured so that evidence is clear, and findings can be shared in a factual report.

How Findings Are Shared

SCR reports are written for public access, but personal details of the child and family are removed. The reports are often published online by the safeguarding partnership. Schools and other agencies also receive summaries and recommendations.

Reports use clear language so that both professionals and the public can understand the lessons. Managers then share the findings with their teams, often in staff meetings, training events, and written updates.

How SCRs Inform School Practice

In a school setting, serious case reviews can bring about changes in several areas.

Policy Changes

Schools may update safeguarding policies in line with SCR recommendations. This can include:

• Clearer reporting lines for safeguarding concerns
• Stronger checks when a child is absent from school
• Better record keeping systems
• Information sharing agreements with other agencies

Staff Training

Findings from an SCR often lead to refresher safeguarding training. This may focus on topics such as:

• Spotting early signs of neglect or abuse
• Understanding how to record and escalate concerns
• Listening to the child’s voice
• Knowing when and how to refer to children’s social care

Communication Improvements

Some SCRs reveal that communication between professionals was weak. In response:

• Schools can set up regular safeguarding meetings
• Designated Safeguarding Leads (DSLs) can link more closely with health and social care
• Staff can be reminded to log all concerns, even those they think are small

Record Keeping

Poor recording is a common finding in SCRs. Schools can strengthen their systems by:

• Using secure digital recording tools
• Storing written records safely
• Making sure all staff know where and how to log concerns
• Keeping records for the time period required by legislation

Lessons from Past SCR Cases

SCRs have revealed lessons that are directly relevant to school staff.

Case Example: Missed Opportunities

In some cases, schools noticed that a child was withdrawn or had poor attendance but did not follow up with other agencies. The learning was that repeated small signs can add up to a serious safeguarding risk. Staff must not ignore patterns.

Case Example: Poor Information Sharing

A health visitor had information about injuries, but the school did not receive this. The lesson is that information must be shared legally and promptly when a child is at risk.

Case Example: Failing to Hear the Child

In several cases, children had hinted at problems but were not listened to. The lesson for schools is to make sure every disclosure is taken seriously and recorded immediately.

The Role of Designated Safeguarding Leads (DSLs)

DSLs have a central role in applying SCR learning. They:

• Read SCR reports and identify relevant changes for their school
• Share learning outcomes with all staff
• Update safeguarding procedures
• Work with leadership to improve training based on the findings
• Liaise with external agencies to strengthen partnerships

By taking responsibility for translating SCR recommendations into practical actions, DSLs help make sure the school setting responds effectively.

Impact on Inter-agency Cooperation

SCR findings have shaped how schools, social care, police, and health staff work together. Reviews have shown that:

• Agencies must have regular contact
• Information sharing protocols must be clear
• Professionals must challenge each other respectfully if they feel something is being missed
• Safeguarding concerns must be acted on without delay

These lessons encourage a culture where safeguarding is everyone’s business.

Preventing Recurrence of Mistakes

SCRs are intended to stop the same errors from happening again. Schools can act by:

• Reviewing all current safeguarding cases in light of SCR findings
• Checking that staff have up-to-date contact information for local safeguarding partners
• Making sure there are clear internal escalation routes for concerns
• Testing safeguarding procedures regularly so that staff are confident in using them

Embedding Learning into Daily Work

To make learning from SCRs effective, it should not be treated as a one-off task. Schools should:

• Keep SCR learning points alive in regular staff briefings
• Include reminders in school bulletins
• Discuss case lessons during inset and training days
• Display safeguarding flowcharts in staff areas

Embedding the findings into daily routines means the lessons are more likely to be acted on.

Supporting Staff After Learning from SCRs

Reading about tragic cases can be upsetting for staff. Leaders can support by:

• Allowing time for discussion and reflection
• Offering confidential support or counselling
• Acknowledging feelings and encouraging staff to focus on what actions they can take to help protect children

Example Recommendations Applied in Schools

Past SCRs have led to clear recommendations, such as:

• Schools to keep detailed written records of any injuries noticed on a child and to check patterns over time
• DSLs to make sure safeguarding information is passed on when a child changes school
• All staff to challenge non-attendance and follow up welfare concerns with home visits or contact
• Training to include recognising the signs of coercive control in young people’s relationships
• Reviewing policies on safe collection of children at the end of the day to prevent unauthorised adults removing a child

National Use of SCRs

While SCRs are based on local cases, the learning is often shared nationally. National safeguarding bodies produce summaries of common themes so that changes in law, guidance and training can be made.

For example, findings from many SCRs have influenced the content of statutory guidance “Working Together to Safeguard Children”. This guidance sets out expectations for all agencies, including schools, and is revised to reflect what has been learned.

Linking SCR Learning to Ofsted Inspections

Inspectors assess how schools safeguard pupils. They may check if schools:

• Keep up to date with local and national SCRs
• Act on recommendations from reviews
• Maintain thorough safeguarding records
• Train staff regularly in latest safeguarding guidance

By showing that SCR learning is part of school improvement, leaders can demonstrate strong safeguarding practice.

Acting on SCRs Quickly

Time is a key factor. If a report makes a recommendation, this should be acted on promptly so that risks to children are reduced. Delays can leave gaps where harm could occur. Schools that respond quickly demonstrate a commitment to pupil safety.

Using SCRs as Part of Professional Development

SCRs can be case study material in staff training. They provide real examples of where systems failed, making lessons more memorable. Staff can discuss:

• What they would have done in that situation
• Whether the same gaps exist in their setting
• How they could improve collaboration with other professionals

This approach encourages reflective practice.

Final Thoughts

Serious Case Reviews are an important process for learning how to improve safeguarding. They are not about blaming individuals but about understanding what happened and finding ways to prevent it happening again. Schools have a key part to play in acting on the lessons.

By reading SCR reports, updating policies, training staff and improving communication, schools can create a safer environment for all children. The changes made in response to recommendations strengthen safeguarding systems and make joint working more effective.

When schools take SCR learning seriously, they show the whole community that child safety is their top priority. This builds trust with parents, pupils, staff and partner agencies. In the end, the purpose of this learning is simple — to protect children from harm and to act quickly when something is wrong.