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Case Reviews

Sometimes a child suffers a serious injury or death as a result of child abuse or neglect. Understanding not only what happened but also why things happened as they did can help to improve our response in the future. Understanding the impact that the actions of different organisations and agencies had on the child’s life, and on the lives of his or her family, and whether or not different approaches or actions may have resulted in a different outcome, is essential to improve our collective knowledge. Guidance for Statutory Case Reviews Processes 2024 can be accessed here

This page contains an overview of the reviews process and relevant information and guidance relating to safeguarding case reviews undertaken in Warwickshire.

What is a Rapid Review

Chapter 5 of the statutory guidance Working Together to Safeguard Children 2026 places a duty on local safeguarding partnerships to undertake a rapid review for serious child safeguarding cases.

Serious child safeguarding cases are those in which:

  • Abuse or neglect of a child is known or suspected;

and

  • The child has died or been seriously harmed.

Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s:

  • Mental health; or
  • Intellectual, emotional, social, or behavioural development; or
  • Impairment of physical health.

The purpose of a rapid review is to:

  • Gather the facts about the case, as far as they can be readily established at the time;
  • Discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately;
  • Consider the potential for identifying improvements to safeguard and promote the welfare of children;
  • Decide what steps they should take next, including whether or not to undertake a child safeguarding practice review.

All agencies who have been involved with the subject child or family will be required to contribute to the rapid review. An initial scoping of agencies’ intervention will be completed, and other relevant information will need to be rapidly gathered.

To support this, agencies are asked to produce an Individual Agency Summary.

The purpose of the initial scoping and information sharing is to gather the basic facts about the case, including determining the extent of agency involvement with the child and family.

More detailed information will be sought if the rapid review concludes the case has the potential to identify national or local learning and a decision is made to recommend a Child Safeguarding Practice Review, or an alternative Learning Review.

Although any agency can refer a case (see attached referral form) all notifications to Ofsted and the Child Safeguarding Practice Review Panel must come from the Local Authority.

Once the Local Authority notifies Ofsted, this becomes a rapid review referral and Warwickshire Safeguarding will be required to comply with the 15-day timeframe stipulated within Working Together 2026. Click here for an overview of the process

What is a Child Safeguarding Practice Review

A Child Safeguarding Practice Review (CSPR) is an independent review into a case where a child has been seriously harmed or has died and abuse or neglect is known or suspected.  These were formerly referred to as ‘Serious Case Reviews’ and are progressed based on the decision of the Rapid Review, referred to above.

The purpose of reviews of serious child safeguarding cases, at both local and national level, is is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children, young people and families.

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, as there are other processes for that purpose.

Who has responsibility for Local Child Safeguarding Practice Reviews

The safeguarding partners are responsible for commissioning and supervising reviewers for local reviews.

The safeguarding partners should agree with the reviewer the method by which the review should be conducted. The methodology should provide a way of looking at and analysing frontline practice as well as organisational structures and learning. The methodology should be able to reach recommendations that will improve outcomes for children, young people and families.

Safeguarding partners should seek to ensure that:

  • Practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • Families, including surviving children, are invited to contribute to reviews.
How is learning from Child Safeguarding Practice Reviews shared

The responsibility for learning lessons from serious child safeguarding incidents lies with the Child Safeguarding Practice Review Panel at a national level and safeguarding partners at a local level (local authorities, chief officers of police and clinical commissioning groups).

Within Warwickshire, the Safeguarding Reviews Subgroup leads this work at a local level and produces Lessons Learned Briefings and 7 Minute Briefings, which sit alongside the published report.  These briefings provide a summary overview of the story of the child or adult, what we learned and advice for practitioners and the community to support wider learning across the County.

What are the expectations for the final report

Safeguarding partners must ensure that the final report includes:

  • A summary of any recommended improvements to be made by persons in the area to safeguarding and promote the welfare of children;
  • An analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report.

Safeguarding partners must publish the report to support wider learning, unless there are compelling circumstances, where it may not be considered appropriate to do so.

How do I access copies of Warwickshire Safeguarding Child Safeguarding Practice Reviews

Provided below are links to the Child Safeguarding Practice Reviews published by Warwickshire Safeguarding:

Child Safeguarding Practice Reviews Published in 2026 
Coco – Published July 2026

A Child Safeguarding Practice Review has been undertaken in relation to ‘Coco’

Coco Child Safeguarding Practice Review – Report

 

Rosie – Published March 2026

A Child Safeguarding Practice Review has been undertaken in relation to ‘Rosie’

Rosie Child Safeguarding Practice Review – Report

Child Safeguarding Practice Reviews Published in 2025

Marie – Published September 2025

A Child Safeguarding Practice Review has been undertaken in relation to ‘Marie’

Marie Child Safeguarding Practice Review Part One – Report

Marie Child Safeguarding Practice Review Part Two – Report

Marie Child Safeguarding Practice Review – WSCP Response Statement

‘Neglect’ – Published August 2025

A Thematic Child Safeguarding Practice Review has been undertaken in relation to the case of ‘Family A, Family B, and Family C’.

Please see below the report and its findings:

Executive Summary ‘Neglect’ – Report 

Child Safeguarding Practice Reviews Published in 2024
 
Emily & Ryan – Published October 2024
 

A Child Safeguarding Practice Review has been undertaken in relation to the case of ‘Emily & Ryan’.

Please see below for the full report and its findings:

 
Emily & Ryan Child Safeguarding Practice Review – Report
Emily & Ryan Child Safeguarding Practice Review – Lessons Learned Briefing 
 
 
 
Fara- Published August 2024
 

A Child Safeguarding Practice Review has been undertaken in relation to the case of ‘Fara’.

Please see below for the full report and its findings:

Fara Child Safeguarding Practice Review – Report
Fara Child Safeguarding Practice Review – Lessons Learned Briefing
Fara Child Safeguarding Practice Review – WSP Statement
 

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