Safeguarding practice reviews

This page contains relevant information and guidance relating to case reviews published by Warwickshire Safeguarding.

Chapter 4 of the statutory guidance Working Together to Safeguard Children 2018 places a duty on local safeguarding partnerships to undertake a rapid review for serious child safeguarding cases where:

  • 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:
    1. Mental health; or
    2. Intellectual, emotional, social or behavioural development; or
    3. Physical health

Rapid review

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.

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 2018. Click here for an overview of the process.


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.

Case Reviews

Below are links to the child safeguarding practice reviews (Formerly referred to as Serious Case Reviews, prior to the introduction of Working Together 2018) published by the Warwickshire Safeguarding.

A serious case review has been undertaken in relation to the case of child J, a seven month old baby who suffered a serious injury while in the care of her mother. 

The Serious Case Review identified that child J was a healthy, thriving infant whose lived experience ‘was one of safe and nurturing care and a positive relationship with her primary caregiver’; she experienced both love and commitment from her mother, and the nurturing support of an experienced foster carer. The professionals who were working with child J and her mother demonstrated a high level of support and diligence in the care they provided.

Nevertheless, in spite of all these positives, child J suffered a serious injury while in the care of her mother and that injury occurred while she was the subject of a child protection plan designed to keep her safe from harm.

It is from that perspective and in the context of a long-standing involvement of a range of professionals with the family, that Warwickshire Safeguarding Children’s Board commissioned this Serious Case Review and welcomes its findings.

The process of undertaking this SCR and the learning arising from it has been an invaluable experience for all involved. The model of ‘Pathways to harm; pathways to protection’ set forth in the recent Triennial Review of Serious Case Reviews and used as the analytic framework for this review, has lent itself to a depth of learning that is clearly rooted in the case and has been able to identify pertinent learning for the Board and its partners.

As a Board we are extremely grateful to Nicki Pettitt, the lead reviewer, to the members of the review team, to Child J’s mother, and to all those practitioners who contributed to the review.

Download Serious Case Review Child J PDF

Warwickshire Safeguarding Children’s Board (WSCB) has today (1 March) published a serious case review (SCR) following the death of “T” a 23 month old infant.

A Serious Case Review (SCR) is held when abuse or neglect is known or suspected, and either a child has died, or a child has been seriously harmed.

The purpose of serious case reviews is to explore whether there are changes that can be made to the safeguarding “system” so all involved are able to work better together and to reduce the likelihood of a similar event in the future.

“T” was a looked after child who was placed with foster carers registered with Warwickshire County Council. Three months later, ‘T’ tragically died, following admission to hospital with non-accidental injuries.

The foster mother pleaded guilty to the manslaughter of “T” and was sentenced to a term of imprisonment.
The WCSB appointed two independent safeguarding consultants to lead the review.

The review cites their findings which board partners have used to make a number of practice recommendations, and these are already being implemented by the agencies involved. The board will continue to monitor the progress of this work.

Measures brought into place as a result of the review include:

  • Scrutiny of carers and professionals working to safeguard looked after children has been enhanced through approval panels, sharing of performance reports and regular review
  • Improvements arising from a review of fostering services, commissioned by the county council, have been implemented and will be tested through an imminent peer review. Arrangements for seeking medical information from GPs as part of the statutory process for the approval of foster carers have been strengthened
  • A Placement Hub has been developed to support improved practice in making and taking of placement referrals, and to improve matching of children with suitable carers
  • LADO (Local Authority Designated Officer) arrangements in Warwickshire have been enhanced, and the WCSB has sought assurance from agencies and staff that the role of the LADO is understood
  • The designated nurse and doctor are working to create guidance to assist clinicians providing child care protection advice to social workers and police officers in relation to suspected non accidental injuries.

Download Serious Case Review Child T PDF

Warwickshire Safeguarding Childrens Board (WSCB) has undertaken a Serious Case Review following the death of ‘John’ a ten-week-old baby in September 2013.

John, a premature infant, died unexpectedly on the first night his family were staying with extended family after being evicted from their social housing tenancy.

John died after he was brought downstairs for a feed and then slept on the sofa with a parent. When the parent woke John had died. The coroner recorded an open verdict on the death.

Although John did not die as a result of maltreatment, WSCB carried out a review because his circumstances and contact with agencies as a ‘child in need’ met the criteria for a Serious Case Review.

WSCB commissioned two independent safeguarding experts to carry out the review, and speak to all the agencies involved with the case to identify areas of learning. The review, which used Social Care Institute for Excellence (SCIE) ‘Learning Together’ methodology, makes five findings and identifies action to be taken on a single and multi-agency basis.

The review found that agencies working with this family had not fully understood the issues at the heart of the case, and could have done more to mitigate the impact of the family’s eviction. It also found that that there was confusion about the extent of the lead professional’s role during the child’s assessment period.

Measures brought into place as a result of the review include:

  • The housing association now holds an internal case conference including those involved with a family before eviction to ensure all information is considered and if eviction is progressed that a referral is made to children’s social care
  • Training has been developed to ensure professionals making referrals and duty social workers share a better understanding and jointly make decisions so that people receive the right level of help for their needs
  • The Safeguarding Board will clarify the role of the lead professional during an assessment
  • Additional police officers have been trained in responding to unexpected child deaths
  • New paediatricians appointed in Warwickshire are now contracted to be trained to respond to unexpected child deaths
  • The multi-agency safeguarding hub (MASH), which is being developed, will support comprehensive information sharing at the point of referral.

David Peplow, Chair of WSCB, concluded: “We want agencies both in Warwickshire and nationally to learn from this case and improve practice.”

Download the Serious Case Review PDF

Download WSCB Response to John SCR PDF

Learning from a review of Fostering and Adoption Services -  January 2018

A recent independent review was completed of the Adoption and Fostering Services in Warwickshire, which considered the importance of how the sharing of information between teams contributes towards robust and accurate assessment of carers.  Adopting a child is different from fostering; both carry an imperative on the carer to provide for and respond to the child's needs, but in very different circumstances.  

The learning that the review identified has now been published for sharing and wider dissemination.  To access, click here.


Latest News

Keep up to date with the latest safeguarding news.

Safeguarding Adults News

Safeguarding Children News
Safeguarding Family News

Safeguarding Briefings

Click below for the latest briefings from Warwickshire Safeguarding!

7-Minute Briefings
Lessons Learnt Briefings

Contact us today using the details from our Contact Us webpage to find out how we can help


Contact Us

Warwickshire Safeguarding Adults Board /
Warwickshire Safeguarding Children's Board
Saltisford Buildings
Ansell Way
Saltisford, Warwick
CV34 4UL


Adults/Children's: 01926 410410

Follow Us: facebook twitter google-plus

Safeguarding Children

Website Feedback