Serious case reviews
Ofsted’s latest report evaluating serious case reviews has found that although local areas are learning lessons from reviewing cases, more needs to be done to ensure the review process improves the way children across the country are protected from harm.
The law states that every children’s services 
authority must have a Local Safeguarding Children Board (LSCB) whose role includes looking at how the council and its partners in each local area work together effectively to safeguard and promote the welfare of children in that locality. The Board reviews cases where a child dies, is seriously injured or suffers a permanent impairment to health and development as a result of abuse or neglect. The aim of the review is to identify action that can improve inter-agency working and better safeguard and promote the welfare of children.
A larger number of Boards are reviewing a greater number of cases. They are also co-operating more readily where a review spans more than one area
Ofsted looked at 173 serious case reviews carried out in 2008-09 and found 23 per cent to be good and 43 per cent to be adequate. However over a third of reviews (34 per cent) were judged as inadequate. The reviews relate to 219 children – some deal with more than one child in a family - and include 113 cases of child deaths as a result of an incident. Of the 219 children identified, 68 per cent were known to social care services at the time of the incident.
Ofsted’s report, Learning lessons from serious case reviews: year 2, has found evidence to suggest that LSCBs are carrying out their serious case reviews more quickly and with greater levels of independence. A larger number of Boards are reviewing a greater number of cases. They are also co-operating more readily where a review spans more than one area.
However, the findings show that weaknesses identified in Ofsted’s previous report, Learning lessons, taking action: Ofsted’s evaluations of series case reviews 1 April 2007 to 31 March 2008, still exist across the various groups. Instances of weak management and lack of joint working within and across agencies remain in some areas. Other examples of weak practice include failure to focus on the needs of the child, insufficient staff expertise, not making adequate risk assessments, and poor identification of ethnic or social cultural issues.
‘We all have a duty to protect children from harm. It is crucial that those involved in child protection use the serious case review process to deliver change and improvement’
Christine Gilbert, Her Majesty’s Chief Inspector, said, ‘Serious case reviews have a vital part to play in the protection of children. There are encouraging signs of improvement identified in this report. 
Agencies and local authorities are looking more rigorously at their processes and practices to learn lessons from tragic incidents. Learning these lessons will help protect more children from harm. However, much more work needs to be done to address the remaining weaknesses and to ensure that lessons lead to improved outcomes for children and young people.
'It is of great concern that over a third of reviews were judged inadequate in the period covered by the recent report. However, it is important to note that there has been a continuing and impressive improvement in the quality of the reviews evaluated by Ofsted since the period covered by the report. From 1 April 2009 to 30 September 2009 the proportion of serious case reviews judged inadequate reduced to just over 20%.
‘The report provides examples of good practice and I hope local authorities and other agency professionals will find these useful when conducting their own reviews or implementing an action plan for improvement. We all have a duty to protect children from harm. It is crucial that those involved in child protection use the serious case review process to deliver change and improvement.’
The report, Learning lessons from serious case reviews: year 2, can be found at www.ofsted.gov.uk/publications/090101
After evaluating serious case reviews by local authorities, Ofsted produces a list of outcomes on a quarterly basis. The latest list, Serious case review evaluations 1 April 2007 - 30 September 2009, can be found on the Ofsted website at www.ofsted.gov.uk/publications/080278
