2.5 Serious Case Review (including MKSCB Summary of Process and Flowchart)

Please note the information in this chapter is taken from Working Together to Safeguard Children (2015) Chapter 4 Learning and Improvement Framework, Serious Case Reviews.

Additional information can be found in the Milton Keynes Summary of the SCR Process and Flowchart and the Milton Keynes Safeguarding Children Board website for the SCR Toolkit.

The Milton Keynes Interagency Interface between serious incidents reporting in health services, serious case reviews and child death reviews can be accessed here for further details.


1. Serious Case Reviews

Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely:

  1. (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned;
  2. For the purposes of paragraph (1) (e) a serious case is one where:
    1. Abuse or neglect of a child is known or suspected; and
    2. Either: -
      1. The child has died; or
      2. 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.

Cases which meet one of these criteria (i.e. regulation 5(2)(a) and (b)(i) or 5 (2)(a) and (b)(ii) above) must always trigger an SCR. In addition, 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, or where the child was detained under the Mental Health Act 2005. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide.

Where a case is being considered under regulation 5(2)(b)(ii), unless it is clear that there are no concerns about inter-agency working, the LSCB must commission an SCR. The final decision on whether to conduct the SCR rests with the LSCB Chair. If an SCR is not required because the criteria in regulation 5(2) are not met, the LSCB may still decide to commission an SCR or they may choose to commission an alternative form of case review.

LSCBs should consider conducting reviews on cases which do not meet the SCR criteria. They will also want to review instances of good practice and consider how these can be shared and embedded. LSCBs are free to decide how best to conduct these reviews. The LSCB should oversee implementation of actions resulting from these reviews and reflect on progress in its annual report.

2. National Panel of Independent Experts on Serious Case Reviews

Since 2013 there has been a national panel of independent experts to advise LSCBs about the initiation and publication of SCRs. The role of the panel is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory SCR criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel also reports to the Government their views of how the SCR system is working.

The panel's remit includes advising LSCBs about:

  • Application of the SCR criteria;
  • Appointment of reviewers; and
  • Publication of SCR reports.

LSCBs should have regard to the panel's advice when deciding whether or not to initiate an SCR, when appointing reviewers and when considering publication of SCR 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 SCR reports and invitations to attend meetings.

In doing so LSCBs will be exercising their powers under Regulation 5(3) of the Local Safeguarding Children Board Regulations 2006 which states that 'an LSCB may also engage in any other activity that facilitates, or is conducive to, the achievement of its objective'.

3. Serious Case Review Checklist

  • Decisions whether to initiate an SCR;

    The LSCB for the area in which the child is normally resident should decide whether an incident notified to them meets the criteria for an SCR. 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 SCR process;

    The LSCB must let Ofsted and the national panel of independent experts know their decision;

    If the LSCB decides not to initiate an SCR, their decision may be subject to scrutiny by the national panel. The LSCB should provide information to the panel on request to inform its deliberations and the LSCB Chair should be prepared to attend in person to give evidence to the panel;
  • Appointing reviewers;

    The LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this guidance. The lead reviewer should be independent of the LSCB and the organisations involved in the case. The LSCB should provide the national panel of independent experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCB should consider carefully any advice from the independent expert panel about appointment of reviewers;
  • Engagement of organisations;

    The LSCB should ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family. The priority should be to engage organisations in a way which will ensure that important factors in the case can be identified and appropriate action taken to make improvements. The LSCB may decide as part of the SCR to ask each relevant organisation to provide information in writing about its involvement with the child who is the subject of the review;
  • Timescale for SCR completion;

    The LSCB should aim for completion of an SCR within six months of initiating it. If this is not possible (for example, because of potential prejudice to related court proceedings), every effort should be made while the SCR is in progress to: (i) capture points from the case about improvements needed; and (ii) take corrective action;
  • Agreeing improvement action;

    The LSCB should oversee the process of agreeing with partners what action they need to take in light of the SCR findings;
  • Publication of reports;

    All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB's website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case;
  • Final SCR reports 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.

LSCBs should publish, either as part of the SCR report or in a separate document, information about: actions which have already been taken in response to the review findings; the impact these actions have had on improving services; and what more will be done.

When compiling and preparing to publish reports, LSCBs should consider carefully how best to manage the impact of publication on children, family members and others affected by the case. LSCBs must comply with the Data Protection Act 1998 in relation to SCRs, including when compiling or publishing the report, and must comply also with any other restrictions on publication of information, such as court orders.

LSCBs should send copies of all SCR reports to the national panel of independent experts at least one week before publication. If an LSCB considers that an SCR report should not be published, it should inform the panel which will provide advice to the LSCB. The LSCB should provide all relevant information to the panel on request, to inform its deliberations.

This page is correct as printed on Wednesday 11th of December 2019 12:30:42 AM please refer back to this website ( for updates.