Safeguarding

Serious Case Reviews: Learning Lessons for Social Work Practice

January 2025•13 min read

Understanding Case Reviews

Serious Case Reviews (SCRs), now known as Child Safeguarding Practice Reviews (CSPRs), are conducted when a child dies or is seriously harmed and abuse or neglect is known or suspected to be a factor. Their purpose is not to blame individuals but to learn lessons that can improve practice and prevent future harm.

Similarly, Safeguarding Adult Reviews (SARs) are conducted for adults at risk. The learning from all these reviews provides invaluable insight into how systems fail and how practice can improve.

Common Themes from Reviews

Across decades of reviews, certain themes recur repeatedly. Understanding these themes helps us identify and address risks in our own practice.

1. The Child Not Being Seen

  • Children not seen at all, or not seen alone
  • Children seen but not observed or listened to
  • Focus on adult issues rather than the child's experience
  • Not adapting communication to the child's needs

Learning: Always see the child, observe them carefully, speak to them alone where appropriate, and keep their daily lived experience central to your assessment.

2. Information Sharing Failures

  • Agencies holding information in silos
  • Not sharing relevant concerns
  • No one seeing the full picture
  • Fear of data protection preventing sharing

3. Disguised Compliance

  • Parents appearing to engage while not making genuine change
  • Professionals being reassured by surface cooperation
  • Focus on parental engagement rather than child outcomes

4. The Invisible Male

  • Fathers and male partners not seen or assessed
  • Unknown males in the household
  • Focus on mothers without including fathers
  • Perpetrators not identified or managed

5. Professional Optimism

  • Over-optimism about parents' ability to change
  • Believing what professionals want to believe
  • Focusing on small positives while minimising significant concerns

6. Lack of Professional Curiosity

  • Accepting explanations without questioning
  • Not following up on concerns
  • Taking things at face value
  • Not asking "what if?"

7. Threshold and Drift Issues

  • Cases not meeting threshold when they should
  • Thresholds applied inconsistently
  • Cases drifting without progress
  • Repeated referrals not triggering concern

8. Neglect Not Addressed

  • Cumulative harm not recognised
  • Normalisation of poor care
  • Start again syndrome after each incident
  • Lack of urgency in response to neglect

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Applying Learning to Practice

Reflective Questions

For each case, ask yourself:

  • When did I last see this child alone?
  • What do I know about all adults in the household?
  • Am I focused on what the child experiences daily?
  • Am I being professionally curious?
  • Am I accepting explanations too easily?
  • What don't I know that I should?
  • Who else holds information I need?
  • Is this case drifting?

Practical Actions

  • Use chronologies to spot patterns
  • See and speak to children routinely
  • Identify and assess all significant adults
  • Share information proactively
  • Challenge disguised compliance
  • Use supervision to test your thinking
  • Escalate when you have concerns

Learning From National Reviews

The Child Safeguarding Practice Review Panel publishes national reviews on themes affecting multiple cases. Key national reviews have addressed:

  • Sudden unexpected death in infancy
  • Child criminal exploitation
  • Children with disabilities
  • Domestic abuse
  • Mental health of parents

Embedding Learning

For learning to make a difference, it must be embedded in practice:

  • Read summaries of local and national reviews
  • Discuss reviews in team meetings and supervision
  • Apply learning to current cases
  • Challenge practice that doesn't reflect learning
  • Contribute to learning events

The Review Process

If you're involved in a case that becomes subject to review:

  • Cooperate fully with the review
  • Provide honest accounts of your involvement
  • Submit records and documents as requested
  • Reflect on your practice without defensiveness
  • Seek support from your manager and union
  • Remember: reviews are about learning, not blame

Systems Thinking

Modern reviews use systems thinking—recognising that outcomes result from how the whole system functions, not just individual actions. This means:

  • Understanding the context professionals were working in
  • Examining organisational factors, not just individual decisions
  • Looking at how systems interact
  • Making recommendations that address systemic issues

Conclusion

Learning from reviews is not optional—it's a professional responsibility. The themes that emerge repeatedly tell us where practice most often goes wrong: not seeing the child, not sharing information, accepting surface compliance, and losing professional curiosity.

Apply this learning to every case. Ask the difficult questions. Challenge when things don't seem right. The children and adults we work with depend on us learning from what has gone wrong before.