A Guide to Child Safeguarding Practice Reviews

In 2018, the Department for Education reported that 53,790 children in the UK were being supported through a child protection plan, indicating the largest increase since 2014. Research done by the NSPCC in 2020 on the risk of child abuse in relation to the pandemic found that national lockdowns and isolation were likely to increase the risk of children being abused by their parents or carers, which recent cases such as that of Arthur Labinjo-Hughes and Star Hobson have tragically proved to be true.

Child safeguarding practice reviews are required in instances like those mentioned above where children come to serious harm following abuse and neglect. They act as a valuable tool for highlighting issues with safeguarding services and indicating where more work is needed to protect vulnerable children, helping local and national organisations implement new schemes and procedures to reduce child abuse.

This article explains the purpose and history of the current Child Safeguarding Practice Review policy, along with outlining the processes involved.

What is a Child Safeguarding Practice Review?

Child Safeguarding Practice Reviews (CSPRs) are systematic reviews of serious child safeguarding cases at both a local and national level. They are used to investigate the causes of cases of abuse or neglect to identify whether there are changes that should be made at a local or national level to stop these kinds of cases from happening again.

CSPRs are undertaken at a local level by Local Safeguarding Children Partnerships (LSCPs), formerly Local Safeguarding Children Boards (LSCBs). At a national level, these reviews are completed by the Child Safeguarding Practice Review Panel.

Serious child safeguarding cases are defined as cases in which abuse or neglect of a child is known or suspected, and the child has died or been seriously harmed as a result of this abuse. Serious harm is defined as serious immediate harm or injury or any longer-term impairments, including conditions that affect physical, mental, intellectual, emotional, social and behavioural development.

The overall purpose of a Child Safeguarding Practice Review is to identify steps that various organisations and professionals should have taken to prevent harm, and reduce or remove the likelihood of another situation happening so severely again. 

Some of the other aims of the CSPRs are

• To examine how local professionals and organisations worked together to safeguard the child or young person who was harmed
• To consider what happened and where local services failed that meant a child or young person experienced abuse or neglect unnoticed
• To assist organisations in improving safeguarding practice and policy to improve the effectiveness of child protection systems
• To understand what practices were already in place from the perspective of the individuals and organisations involved at the time, and why these were deemed to be sufficient to keep the child safe
• To focus on learning and improving safeguarding practices, rather than holding individuals, organisations and agencies accountable and passing blame
• To translate findings into actions that support and underpin sustainable change and improvement, in order to prevent or reduce the risk of recurrence of similar incidents of abuse

History of Child Safeguarding Practice Reviews

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 from this concept to go beyond simply describing what happened in the event of a public scandal or tragedy, and instead analyse and identify what went wrong with a view to identifying key actions for improvements in child safeguarding practice.

Serious Case Reviews were first introduced as part of the Children Act (2004) to respond to cases where a child has died as the result of abuse or neglect.

The current process involved in child safeguarding practice reviews was inspired by The Munro Review of Child Protection (2011) which was an independent review of England’s child protection services carried out by Professor Eileen Munro and commissioned by Michael Gove, former Secretary for Education. This review stressed the need to focus on causation in cases of serious child abuse to establish clear actions for improvement.

In 2018, Serious Case Reviews were replaced with Child Safeguarding Practice Reviews (CSPRs) as part of the ‘Working Together to Safeguard Children’ initiative. The processes and requirements of these reviews are outlined below.

Child Safeguarding Practice Review Process

There are two kinds of official Child Safeguarding Practice Review; local and national. Local reviews involve a consideration of the local safeguarding services and the issues that a case raises on their effectiveness in an area, whilst national reviews investigate cases of abuse that raise issues that are deemed complex or of national importance.

Local Review

Local Child Safeguarding Practice Reviews are undertaken by Local Safeguarding Children Partnerships. These partnerships consist of at least three safeguarding partners, which under the Children Act (2004) include the local authority, the clinical commissioning group and the chief officer of police. Most partnerships will often also consist of other agencies and organisations that are considered essential to achieving effective child protection practice.

In the event of a serious case of child abuse or neglect, leading to the death or serious harm of a child, local authorities are responsible for notifying the Child Safeguarding Practice Review Panel and their local safeguarding partners within five days. If a child has died, the Secretary of State and Ofsted must be notified, even if abuse or neglect wasn’t known or suspected.

The organisation involved in Local Safeguarding Children Partnerships must then commission and oversee a review of this case of abuse if it raises issues or questions about the quality of services in the area. They are then required to undertake a rapid review of the case if immediate action is required to ensure a child’s safety, and then send this ​​rapid review to the Child Safeguarding Practice Review Panel.

Not all serious cases of child abuse will review an official review. It is only required if the Local Safeguarding Children Partnerships believe that the case indicates an issue that all partners should be aware of, or if it is believed that learning can take place from a thorough investigation of the case.

A ‘good’ review report is regarded by the Child Safeguarding Practice Review Panel as one that involves:

• A summary of the case’s context, background and circumstances
• Details of the decisions that were taken by professionals involved in the case
• Critical analysis of how different local agencies worked together and any shortcomings of this work
• Investigation into whether these shortcomings are features of the local approach and practice for safeguarding
• Speculation on what should be done to prevent a similar situation from occurring
• Recommendations for next steps to ensure all agencies learn from the case 

National Review

National Child Safeguarding Practice Reviews are conducted by a Child Safeguarding Practice Review Panel. This panel aims to look at how practice can be improved and what needs to be changed at a national level when it comes to safeguarding procedures and can commission reviews of serious child safeguarding cases where necessary.

When a national review is required in response to a case of child abuse, it is because the issues highlighted by the case are deemed to be of national importance because of their potential implications for other vulnerable children. A review may also be required if the issues raised by a case are deemed too complex for a local organisation to deal with.

This panel is responsible for liaising with local safeguarding partners and other involved parties to organise a complete review of a child abuse or neglect case, agreeing on the appropriate methodology and deciding on the scope of the review. They will then decide on the action that needs to be taken in response to this review, which may involve changes to legislation or updates to existing safeguarding guidelines.

Common questions asked by the Review Panel before taking action include:

• What happened?
• 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 how agencies operate could help to prevent abuse/neglect? What actions 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?

Historic Public Inquiries and Serious Case Reviews

Before the introduction of the 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 practices, some of which have been significant in driving change and improvement. 

You can read more about these high-profile cases below.

• 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, which you can access here.

FAQs

What is a serious case review in safeguarding?

In child safeguarding, a serious case review is a review process that takes place to examine the events that have led up to a child being seriously harmed or killed as the result of abuse. The specifics of each process vary in the different nations around the UK, but in England, this process is known as child safeguarding practice reviews. 

When should a safeguarding review be carried out?

A safeguarding review must be carried out if a child or an adult dies as the result of abuse. They are also often carried out if a child or adult suffers serious harm after abuse or neglect.

Summary

Whilst serious cases of child abuse are harrowing, the official reviews that come from these cases allow us an opportunity to investigate how local and national safeguarding services might be failing to keep children in the UK safe. By interrogating these processes and identifying areas for improvement, safeguarding services across the country will improve and more children will be kept safe, reducing the risk of serious abuse or neglect and helping to end the trauma still faced by many young people today.

To see our full range of online safeguarding courses, please click here.