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Bury Integrated Safeguarding Partnership

Working together to safeguard adults and children in Bury

Serious Case Reviews and Safeguarding Adult Reviews

All Local Safeguarding Partnerships are required to conduct Serious Case Reviews in accordance with Working Together to Safeguard Children (2015) and Safeguarding Adult Reviews in accordance with the Care Act (2014).

What are Serious Case Reviews?

Local Safeguarding Children Boards should always undertake a serious case review when abuse or neglect of a child is known or suspected; and either

  • the child has died (including death by suspected suicide); or
  • the child has been seriously harmed and there is cause for concern as to the way in which the authority, their partners or other relevant persons have worked together to safeguard the child.

In addition, a Serious Case Review should always be carried out when a child dies in custody, in police custody, in a training centre or in a secure children's home or where the child was detained under the Mental Health Act 2005. If you require a copy of a report of an older serious case review, please contact the BISP team.

For further information on case reviews, please see the Case reviews referral process and the Greater Manchester Safeguarding Procedures - Case Review Processes.

NSPCC National Repository of Serious Case Reviews

Sadly the cases of Daniel Pelka, Keanu Williams and Hamza Khan have raised the profile of Serious Case Reviews nationally. The national repository of published case reviews is a collaboration between the NSPCC and the Association of Independent LSCB Chairs. The aim is to hold all case reviews in a central location, so the learning contained within them is easier to access. Access to the electronic versions of the case review reports stored by the NSPCC is available by accessing Learning.nspcc - Library catalogue.

What are Safeguarding Adult Reviews?

A Safeguarding Adult Review is a multi-agency process that considers whether or not serious harm experienced by an adult, or group of adults at risk of abuse or neglect, could have been predicted or prevented. The process identifies learning that enables the partnership to improve services and prevent abuse and neglect in the future.

What are Critical Case Reviews?

Local Safeguarding Children Boards are also required to review child protection incidents which fall below the threshold for a Serious Case Review; and review or audit practice in one or more agencies involved in the case. In Bury, these types of reviews are called Critical Case Reviews.

  • The following principles should be applied by LSCBs and their partner organisations to all reviews:
    There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. Bury Integrated Safeguarding Partnership regularly hold programmes of Serious Case Review Learning Events to cascade the learning from recent Serious Case Reviews.
    Further details can be found on Training
  • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined
  • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed
  • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith
  • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process
  • Final reports of Serious Case Reviews must be published, including the LSCB's response to the review findings, in order to achieve transparency. This has been the case since June 2010. Prior to this, Local Safeguarding Children Boards were only required to publish Executive Summaries.
  • The impact of Serious Case Reviews and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections.
  • Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children.

 For further information, please see the Case reviews referral process and the Greater Manchester Safeguarding Procedures - Case Review Processes.