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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.

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

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.

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 2018. Click here for an overview of the process



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.



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.


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.



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 (Formerly referred to as Serious Case Reviews, prior to the introduction of Working Together 2018) published by Warwickshire Safeguarding:

Simon - Published September 2023

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

Please see below for the full report and its findings:

Simon Child Safeguarding Practice Review - Report
Simon Child Safeguarding Practice Review - Lessons Learned Briefing 

7 Minute Briefing - Suicide Awareness
7 Minute Briefing - The Importance of History in Assessments 
7 Minute Briefing - Use of Interpreters and Translators

Anna - Published September 2023

An Alternative Learning Review has been undertaken in relation to the case of 'Anna’.

Please see below for the full report and its findings:

Anna Alternative Learning Review – Report

Anna Alternative Learning Review - Lessons Learned Briefing

7-Minute Briefing - Escalation Protocol

7-Minute Briefing - The Importance of History in Assessments 

7-Minute Briefing - Children of parents with Mental Health problems

7-Minute Briefing - Early Help

7-Minute Briefing - New partners joining households

7-Minute Briefing - Parental Capacity to Change

7-Minute Briefing - Suicide Awareness

7-Minute Briefing - The links between child/vulnerable adult and animal abuse


Grace - Published September 2022

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

Please see below for the full report and its findings:

Grace Child Safeguarding Practice Review - Report 
Grace Child Safeguarding Practice Review - Lessons Learned Briefing 

7 Minute Briefing - Child Neglect 
7 Minute Briefing - Children of Parents with Mental Health Problems
7 Minute Briefing - Children of Parents who Misuse Substances 
7 Minute Briefing - Parental Capacity to Change
7 Minute Briefing - Suicide Awareness
7 Minute Briefing - The Importance of History in Assessments 
7 Minute Briefing - The Voice of the Child 
7 Minute Briefing - Underage Sexual Activity

James - Published June 2022

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

Please see below for the full report and its findings:

James Child Safeguarding Practice Review - Report

James Child Safeguarding Practice Review - Lessons Learned Briefing

7 Minute Briefing – Children on Part Time or Reduced Timetables

Charlie - Published April 2022

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

Please see below for the full report and its findings:

Charlie Child Safeguarding Practice Review - Report

Charlie Child Safeguarding Practice Review - Lessons Learned Briefing

7 Minute Briefing - The Importance of History in Assessments
7 Minute Briefing - Children Home Alone
7 Minute Briefing - Professional Curiosity
7 Minute Briefing - The Voice of the Child
7 Minute Briefing - Child Neglect
7 Minute Briefing – Safeguarding Children around Dog
7 Minute Briefing - Child Accident Prevention
7 Minute Briefing - Contacting the Children and Families Front Door
7 Minute Briefing - Early Help

Prada and Jordan - Published March 2022

A Child Safeguarding Practice Review has been undertaken to the relation to the case of 'Prada and Jordan'.

Please see below for the full report and a statement issued by Warwickshire Safeguarding Partnership:

Prada and Jordan Child Safeguarding Practice Review – Report

Prada and Jordan – Lessons Learned Briefing

Escalation Protocol – 7-minute Briefing




Jack - Published October 2021

A Child Safeguarding Practice Review has been undertaken to the case of 'Jack'

Please see below for the full report and a statement issues by Warwickshire Safeguarding Partnership:

Jack Child Safeguarding Practice Review - Report

Jack Child Safeguarding Practice Review - WSP Statement

Jack - Lessons Learned Briefing

Use of Alcohol in Children and Young People - 7-minute Briefing




Alice and Beth - Published September 2020

A Serious Case Review has been undertaken in relation to the case of ‘Alice and Beth’.

Please see below for the full report and a statement issued by Warwickshire Safeguarding Partnership:

Alice and Beth Serious Case Review - Report

Alice and Beth Serious Case Review - WSP Statement

Alice and Beth - Lessons Learned Briefing

Professional Curiosity - 7-minute Briefing
Children moving across local authority boundaries - 7-minute Briefing

Sophie - Published July 2020

A Serious Case Review has been undertaken in relation to the case of 'Sophie'.

Please see below for the summary of the full report and its findings:

Final Report - WSCB SCR Sophie

Child K - Published February 2020

A Serious Case Review has been undertaken in relation to the case of 'Child K'.

Please see below for the full report and its findings:

Final Report - WSCB Review Child K

Amy - Published January 2020

A Serious Case Review has been undertaken in relation to the case of ‘Amy’.

Please see below for the full report and its findings:

Final Report - Learning from Amy

Amy - Lessons Learned Briefing



 Reports published prior to 2020 are available via the West Midlands Manual - please click here.

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