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8.1 Learning and Improvement Framework


This chapter covers the requirements within Working Together to Safeguard Children and while local safeguarding children boards transition to the new arrangements by 29th September 2019, which describes the way that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. It explains the requirements for an integrated local learning and improvement framework and the principles to be used when undertaking Serious Case Reviews, as well as other forms of reviews and audits.


Serious Case Review Quality Markers - Supporting dialogue about the principles of good practice and how to achieve them (NSPCC)


This chapter was updated in September 2018 to reflect transition processes towards the new arrangements from Working Together to Safeguard Children.


1. Principles
  1.1 Learning and Improvement Framework
  1.2 Purpose of Local Framework
  1.3 Principles for a Culture of Continuous Improvement
2. Serious Case Review Process
  2.1 Criteria
  2.2 Decisions Whether to Initiate a Serious Case Review
  2.3 National Panel of Independent Experts on Serious Case Reviews
  2.4 Methodology for Learning and Improvement
  2.5 Appointing Reviewers
  2.6 Timescale for Serious Case Review Completion
  2.7 Engagement of Organisations
  2.8 Agreeing Improvement Action
  2.9 Publication of Reports
  2.10 Sharing Learning

1. Principles

1.1 Learning and Improvement Framework

Working Together to Safeguard Children requires that the Local Safeguarding Children Board maintain a shared local learning and improvement framework across those local organisations working with children and families.

This local framework covers the full range of single and multi-agency reviews and audits which aim to drive improvements to safeguard and promote the welfare of children. The different types of review include:

1.2 Purpose of Local Framework

The aim of this framework is to enable local organisations to improve services through being clear about their responsibilities to learn from experience and particularly through the provision of insights into the way organisations work together to safeguard and protect the welfare of children.

This should be achieved though:

  • Reviews conducted regularly;
  • Such reviews to encompass both those cases which meet statutory criteria (i.e. Serious Case Reviews and child death reviews) and cases which may provide useful insights into the way organisations are working together to safeguard and protect the welfare of children;
  • Reviews examining what happened in the case, why it did so and what action will be taken to learn from the findings;
  • Learning from both good and more problematic practice about the organisational strengths and weaknesses within local services to safeguard children;
  • Implementation of actions arising from the findings which result in lasting improvements to services;
  • Transparency about the issues arising and the resulting actions organisations take in response to the findings from individual cases, including sharing the final reports of Serious Case Reviews with the public.

Reviews are not an end in themselves, but a method to identify improvements needed and to consolidate good practice. The LSCB and partner organisations will translate the findings from reviews into programmes of action which lead to sustainable improvements.

1.3 Principles for a Culture of Continuous Improvement

There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, so as to identify what works and what promotes good practice.

Within this culture the principles are:

  • A proportionate response: according to the scale and level of complexity of the issues being examined i.e. the scale of the review is not determined by whether or not the circumstances meet statutory criteria;
  • Independence: Reviews of serious cases to be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
  • Involvement of practitioners and clinicians: Professionals should be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • Offer of family involvement: Families, including surviving children, should be invited to contribute to reviews and be provided with an understanding of how this will occur;
  • The child to be at the centre of the process;
  • Transparency achieved by publication of the final reports of Serious Case Reviews and the LSCB’s response to the findings. The LSCB annual reports will explain the impact of Serious Case Reviews and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children. This will also inform inspections;
  • Sustainability: improvement must be sustained through regular monitoring and follow-up so that the findings from these reviews make a real impact on improving outcomes for children.

2. Serious Case Review Process

2.1 Criteria

The LSCB must undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 set out the LSCB’s function in undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

A Serious Case Review must always be initiated when:

  1. Abuse or neglect of a child is known or suspected; and
  2. Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

“Seriously harmed” in the context of paragraph 18 below and regulation 5(2)(b)(ii) above includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:

  • A potentially life-threatening injury;
  • Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

The HSCB has decided to include as part of its local working definition of ‘serious harm’, cases of serious sexual abuse, including complex or organised abuse and sexual exploitation.

Cases which meet one of the criteria must always trigger an SCR.

In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in Police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

New guidance from the DfE, following the publication of Notification to New Child Safeguarding Practice Review Panel and Working Together to Safeguard Children states:

LSCBs must continue to carry out all of their statutory functions, until the point at which safeguarding partner arrangements begin to operate in a local area. At the latest this will be by 29 September 2019.

The Government places a high priority on encouraging those who work with children to learn from serious incidents so that practice and services are improved to reduce the risk of future harm to children and to improve their outcomes.

The current national panel of independent experts on serious case reviews (SCRs) (as set out in Working Together to Safeguard Children) met for the last time on 11 June 2018. Since July 2013, it has considered 540 cases where LSCBs proposed not to initiate an SCR, and 86 cases where LSCBs proposed not to publish an SCR. A breakdown of these figures will be included in the panel’s final report which will be published later this year. We acknowledge that the panel has undertaken a significant amount of work on a voluntary basis to bring challenge and scrutiny to the SCR system.

The new Panel will, as part of its role in considering whether to commission national reviews, also consider LSCBs’ decisions on the initiation and publication of SCRs. LSCBs should, therefore, now send all information about decisions not to initiate or to publish an SCR to the new Panel at This should include decisions relating to all child safeguarding incidents notified to Ofsted and DfE before July 2018 but where no further information on the case has been sent to the national panel of independent experts. The new Panel expects to hold its first meeting in early July. In the interim, the DfE may contact LSCBs about any cases outstanding from the former panel, and will give a list of such cases to the new Panel.

Local authorities must notify the national panel and LSCBs within five days of becoming aware of an incident where a child has died or been seriously injured within the local authority area or a child who is normally resident in the local authority area has died or been seriously injured while outside of the UK.

Click here for further guidance.

Click here for the Hertfordshire form.

2.2 Decisions Whether to Initiate a Serious Case Review

The LSCB for the area in which the child is normally resident must decide whether an incident notified to them meets the criteria (see Section 2.1, Criteria) for a Serious Case Review. This decision should normally be made within one month of notification of the incident. The final decision rests with the Chair of the LSCB. The Chair may seek peer challenge from another LSCB Chair when considering this decision (and also at other stages in the Serious Case Review process).

The LSCB must notify Ofsted, the Department of Education and the National Panel of Independent Experts of the decision. A decision not to initiate a Serious Case Review may be subject to scrutiny by the National Panel and require the provision of further information on request and the LSCB chair may be asked to give evidence in person to the panel.

If the Serious Case Review criteria are not met, the LSCB may still decide to commission a Serious Case Review or an alternative form of case review.

2.3 National Panel of Independent Experts on Serious Case Reviews

Working Together to Safeguard Children introduced a National Panel of Independent Experts to advise and support LSCBs about the initiation and publication of Serious Case Reviews. The panel reports to the relevant Government departments their views of how the system is working. LSCBs should have regard to the panel’s advice on:

  • Application of the Serious Case Review criteria: whether or not to initiate a Serious Case Review;
  • Appointment of reviewers;
  • Publication of Serious Case Review reports.

LSCB Chairs and LSCB members should comply with requests from the panel as far as possible, including requests for information such as copies of reports and invitations to attend meetings.

The requirements relating to the National Panel remained the same in Working Together to Safeguard Children.

2.4 Methodology for Learning and Improvement

Working Together to Safeguard Children does not prescribe any particular methodology to use in such continuous learning, except that whatever model is used it must be consistent with the following 5 principles:

  • Recognises the complex circumstances in which professionals work together to safeguard children;
  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
  • Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;
  • Transparency about the way data is collected and analysed; and
  • Makes use of relevant research and case evidence to inform the findings.

Whilst Working Together stops short of advocating any specific method the systems methodology as recommended by Professor Munro (The Munro Review of Child Protection: Final Report: A Child Centred System) is cited as an example of a model that is consistent with these principles.

2.4.1 Some Examples of Models which may be considered

  • SCIE Learning Together* (LT) has been piloted and evaluated during the Working Together consultation period** and is recognised as one which values practitioner contributions, is sympathetic to the context of the case and is experienced as a more transparent process by those involved;
  • Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened;***
  • Child Practice Reviews **** replaced the Serious Case Review system as the statutory guidance in Wales on 01.01.13, This process consists of several inter-related parts: Multi-Agency professional Forums to examine case practice, Concise Reviews in order to identify learning for future practice, and an Extended review which involves an additional level of scrutiny of the work of the statutory agencies;
  • Significant Incident Learning Process (SILP) was developed as a way of providing a process to review cases just below the mandatory threshold for serious case reviews. It has subsequently been used in formal serious case reviews. This approach explores a broad base of involvement including families, frontline practitioners and first line managers view of the case, accessing agency reports and participating in the analysis of the material via a ‘Learning Event’ and ‘Recall Session’;
  • Appreciative Inquiry (AI), rooted in action research and organisational development, is a strengths-based, collaborative approach for creating learning change. SCR’s conducted as an appreciative inquiry seek to create a safe, respectful and comfortable environment in which people look together at the interventions that have successfully safeguarded a child; and share honestly about the things they got wrong. They get to look at where, how and why events took place and use their collective Serious Case Reviews hindsight wisdom to design practice improvements.

Serious case Reviews are not limited to systems methodology; there may be cases which require the inclusion of issues from outside a strictly defined systems model.

* Fish, S., E. Munro, and S. Bairstow, Learning together to safeguard children: developing a multi-agency systems approach for case reviews. 2008, Social Care Institute for Excellence: London)
** Undertaking Serious Case Reviews using the Social Care Institute for Excellence (SCIE) Learning Together systems model: lessons from the pilots. March 2013
*** Root Cause Analysis (RCA) Investigation website
**** Protecting Children in Wales. Guidance for Arrangements for Multi-Agency Child Practice Reviews. 2013

Irrespective of the methodology the emphasis must be on the establishment of a local framework for learning and improvement which will achieve the outcomes set out in Section 1.2, Purpose of Local Framework, and undertaking a review which is proportionate to the scale and level of complexity of the issues being examined.

2.5 Appointing Reviewers

The LSCB will appoint one or more suitable individuals to lead the Serious Case Review. Such individuals should have demonstrated that they are qualified to conduct reviews using the Section 1.3, Principles for a Culture of Continuous Improvement.

The lead reviewer should be independent of the LSCB and the organisations involved in the case.

The LSCB will provide the National Panel of Independent Experts (see Section 2.3, National Panel of Independent Experts on Serious Case Reviews) with the name(s) of the individual(s) appointed to conduct the Serious Case Review and  consider carefully any advice which the panel provides about the appointment(s).

Working Together to Safeguard Children says that reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.

2.6 Timescale for Serious Case Review Completion

The LSCB will aim for completion of the Serious Case Review within six months of initiating it. If this is not possible (e.g. because of potential prejudice to related court proceedings), every effort should be made while the Serious Case Review is in progress to:

  • Capture points from the case about improvements needed; and
  • Take any corrective action identified as required.

2.7 Engagement of Organisations

The LSCB will ensure appropriate representation in the review process of professionals and organisations involved with the child and family.

The LSCB may decide as part of the Serious Case Review to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review. The form in which such written material is provided will depend on the methodology chosen for the review. The individual Organisations will be responsible for ensuring the staff who have been involved with the case are aware that an SCR is being undertaken and that they are informed of the findings from any single agency review.

When the LSCB Case Review Group recommend to the Chair of the LSCB to undertake a Case Review, agencies will be reminded that they should take appropriate steps to lock down their relevant case files and/or ensure that staff access and recording into the case records can be monitored in detail.

2.8 Agreeing Improvement Action

The LSCB will oversee the process of agreeing with partners what action they need to take in light of the Serious Case Review findings. The LSCB will provide a copy of the SCR Report and Action Plan to LSCB Board Members so they can arrange the implementation of the recommendations/actions.

Individual Board Members will be responsible for sharing the findings of the review with their organisation’s staff who have been involved in the case.

2.9 Publication of Reports

In order to provide transparency and to support national sharing of lessons learnt and good practice in writing and publishing such reports, all reviews of cases meeting the Serious Case Review criteria will result in a readily accessible published report on the LSCB’s website. It will remain on the web-site for a minimum of 12 months and thereafter be available on request.

The fact that the report will be published must be taken into consideration throughout the process, with reports written in such a way that publication ‘will not be likely to harm the welfare of any children or Adults at Risk involved in the case’ and consideration given on how best to manage the impact of publication on those affected by the case. The LSCB will comply with the Data Protection Act 1998 and any other restrictions on publication of information, such as court orders.

The final Serious Case Review report should:

  • Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence;
  • Be written in plain English and in a way that can be easily understood by professionals and the public alike; and
  • Be suitable for publication without needing to be amended or redacted.

The LSCB will publish, either as part of the final Serious Case Review report or in a separate document, information about:

  • Actions already taken in response to the review findings;
  • The impact these actions have had on improving services; and
  • What more will be done.

The LSCB will send copies of all Serious Case Review reports to the National Panel of Independent Experts at least one week before publication. If the LSCB considers that a report should not be published, it should inform the panel which will provide advice. The LSCB will provide all relevant information to the panel on request, to inform its deliberations.

2.10 Sharing Learning

Integral to the success of this Learning and Improvement Framework will be the sharing of learning on a wide basis to ensure transparency, accountability and consistent improvement to practice. As such in addition to the statutory requirements on publication Hertfordshire LSCB will look to share the outcomes of Serious Case Reviews (and other case reviews that do not meet the SCR threshold) with its partners.

There will be an expectation placed upon Lead Reviewers, via commissioning arrangements or other means that one or more multi-agency learning events are held to inform local practitioners of the findings from the review.

In addition to this, the findings from the Serious Case Reviews will be considered by the Learning and Development Sub-Group to identify the necessary learning that arises from the review and ensure this is reflected in the future HSCB training programme. There is also an expectation on all partners to take the learning from Serious Case Reviews forward within their own agencies through their own internal training programmes and conferences.

Hertfordshire LSCB will assist partners in the dissemination of information by producing information bulletins and presentations which will be distributed by the Hertfordshire LSCB Learning and Development Sub Group for partners to disseminate within their own organisations.

Click here to view Partnership Case Reviews Guidance for Conducting a Partnership Case Review (PCR).