Learning from Practice Reviews

Undertaking child safeguarding practice reviews is part of the reviewing and investigative function of Multi Agency Safeguarding Arrangements. The SLPR subgroup ensures that:

• Arrangements are in place to identify and review
• reviews are conducted regularly on cases which meet statutory criteria and on other cases which can provide useful insights into multi agency safeguarding practices
• that reviews look at what happened in a case and why, and what action will be taken to learn from the findings
• that actions are monitored through robust quality assurance processes and result in lasting improvements to multi agency safeguarding practices
• that there is transparency about issues arising from cases and how agencies are responding to these, including full publication of reviews where possible

Child Safeguarding Practice Reviews (CSPRs) were formerly known as Serious Case Reviews. This changed on 1^st April 2019 in Sandwell, when the Local Safeguarding Children’s Board was replaced by Sandwell Children’s Safeguarding Partnership (SCSP). Although the essence of the reviews is the same, CSPRs allow for greater creativity and focus on the analysis of serious incidents in order to maximise learning for the wider workforce.

In order for consideration to be given to undertaking a CSPR, two key criteria have to be met:

• The child has died or been seriously harmed
• Abuse or neglect is known or suspected

If these criteria are met, a referral can be submitted by any agency for consideration of a CSPR. This triggers a Rapid Review panel meeting attended by representatives from statutory and partner agencies, who review the available information and make a decision on whether a review of practice is needed, and if so what this review will look like. This takes place within 15 working days of the referral being submitted to the Business Unit.

If a case does not meet the criteria for a CSPR, the SCSP may undertake a different kind of learning review with agencies. Although these aren’t published, the learning is shared with partner agencies and monitored to ensure changes are embedded.

• CSPRs explore how organisations worked together to provide services to the child and their family and what lessons can be learned to reduce the likelihood of similar incidents happening in the future.
• The CSPR is not an enquiry into the child’s death/injury and is completely separate to any investigations by the police or coroner.
• CSPRs should be completed within 6 months however it is not always possible to publish during this timescale if there are ongoing parallel proceedings.
• CSPRs can’t be published until all criminal/coroner proceedings are completed so investigations are not compromised.
• When possible to do so, the published report will be made available on the SCSP website, NSPCC Case Repository and is shared across the partnership.

• An independent author is appointed to oversee the review and write the report. A period of focus for the review, known as the scoping period, is agreed.
• A CSPR panel is convened made up of senior managers from organisations who were involved with the child/family, who meet to look at the work all agencies completed. The CSPR panel will meet with the author to quality assure each version of the report as it develops.
• Multi agency Reflective Learning Events will be held for frontline practitioners/managers who worked directly with the child and family. These interactive sessions will identify and celebrate good practice and areas for improvement – each agency will be asked to identify how they can improve services for families in the future. There is a lot of support which practitioners can access both within their own organisation and through the Business Unit due to the subject matter.
• Where it will not affect parallel proceedings, family members will be asked to contribute to the review process and will be kept up to date on the progress and publication of the report.
• The final version of the report is considered first by the SLPR subgroup, who feedback to their agency’s respective strategic boards, and finally is presented to the SCSP Board meeting by the author for ratification.

The NSPCC maintains a repository of all CSPRs/SCRs which have been published across England as a single point to access and share learning at a local, regional and national level. This can be accessed here: https://learning.nspcc.org.uk/case-reviews/national-case-review-repository

• CSPR Process flowchart
• CSPR Escalation pathway
• CSPR Communications Strategy
• CSPR Referral form – please contact the SCSP Business Unit for further guidance prior to making a referral.