National and Local Child Safeguarding Practice Reviews

Responsibility for safeguarding systems learning lessons from serious child safeguarding incidents now rests at a national level with the Child Safeguarding Practice Review Panel and at a local level with the three safeguarding partners.  Local areas no longer conduct Serious Case Reviews, and instead consider whether to conduct a local child safeguarding practice review.

A local child safeguarding practice review is carried out by the Plymouth Safeguarding Children Partnership if there is a serious child safeguarding case.   A serious child safeguarding case is defined by Working Together to Safeguard Children 2018 as a case in which abuse or neglect of a child is known or suspected and the child has died or been seriously harmed.     The full criteria for carrying out a local child safeguarding practice review is detailed in Chapter 4 of Working Together to Safeguard Children 2018.

The purpose of a child safeguarding practice review is to identify how improvements can be made to safeguard and promote the welfare of children.  Reviews should seek to prevent or reduce the risk of recurrence of similar incidents.  They are not conducted to hold individuals, agencies or organisations to account as there are other processes for that purpose, including through employment law, professional regulation, and in exceptional cases criminal proceedings.    Requirements for change and development that come to light in the process of the review will be acted upon in a timely matter and in advance of the publication of the review when appropriate.

Reviews are about promoting and sharing information about improvements, both within the Plymouth and potentially beyond, so safeguarding partners must publish the report. Published reports or information must be publicly available for at least one year. The NSPCC  National case review repository holds copies of published reports, making it easier to access and share learning and can be accessed at

Serious Case Reviews

Local Safeguarding Children Boards (LSCBs) were established as part of the Children Act (2004) and played an important role in challenging safeguarding practice and assessing the effectiveness of safeguarding services in their area.

Each local authority was required to set up an LSCB to bring key agencies such as police, probation, youth justice, heath, education and social care together to make sure local safeguarding of children is effective. In addition to coordinating and ensuring the effectiveness of what is done by each agency to safeguard and promote the welfare of children, LSCBs also undertook serious case reviews (SCR) where a child has been killed or seriously harmed, and abuse or neglect is known or suspected.

Under the Children Act 2004, as amended by the Children and Social Work Act 2017, LSCBs were replaced with new arrangements put in place by the three safeguarding partners (local authorities, chief officers of police and clinical commissioning groups) to work together with relevant agencies to safeguard and protect the welfare of children in the area. These arrangements came into effect on 29 September 2019 and can be seen at

Some LSCB SCRs were not completed and/or published at the point the new safeguarding arrangements began to operate. Where this is the case transitional arrangements allow LSCBs to continue for a ‘grace period’ of a maximum of 12 months from that point to complete and publish these SCRs.  The latest date for completion and publication of an LSCB SCR is 29 September 2020.

Serious Case Review Baby F

The Plymouth Safeguarding Children Partnership has published the findings of its serious case review Baby F

Serious Case Review Baby G

The Plymouth Safeguarding Children Partnership has published the findings of its serious case review Baby G