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Serious Case Reviews (SCRs)

Chapter 4 of Working Together to Safeguard Children (DfE, 2015) sets out the criteria for a Serious Case Review. A Serious Case Review should be carried out for every case where abuse or neglect is known or suspected and either a child dies; or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. Other learning reviews can be carried out by the LSCB if the criteria is not met.

It is important for the multi-agency network to understand the learning from reviews and take the necessary steps to address the issues identified in order to make Greenwich a safer place for children to live. Any review should enable local partner agencies to be clear about their responsibilities, to learn from experience and improve services as a result.

The GSCB have a Serious Case Review Work Group which considers how to review a case, how lessons will be shared and monitors the implementation of the action plan agreed by the Board.

At the end of each Serious Case Review, a SCR Final Report is agreed by the GSCB and published. The most recent reports are listed below:

Serious Case Review - Child X

In May 2017, Young Person X fell from a building in the Royal Borough of Greenwich and died. In March 2018, the Inquest found and concluded that tragically, Young Person X had died from multiple injuries and the reason for his death was suicide. The Inquest also found that no public authority failed in their duty to protect Young Person X. 

The Serious Case Review (SCR) found that this was an unforeseeable incident and that his actions on that day could not have been predicted. However, the SCR did identify that when responding to such complex situations there are lessons to be learned from this tragedy when agencies respond to similarly complex situations in the future.

All agencies involved in his care have already put a number of actions in place. This includes new protocols about how to respond, and an on-going programme of suicide awareness training for Greenwich schools, and for professionals in organisations who work closely with young people.

Download the Child X Serious Case Review report

Download the Child X factsheet

Serious Case Review - Child V

Child V's mother did not engage with antenatal services during her pregnancy other than one scan before the baby was born in August 2016. Child V was born in a hospital outside of London as her mother went into labour whilst visiting her sister. No concerns were noted during her labour and she was discharged soon after the birth to her sister's address before moving back to her home address in Greenwich. Her stated intention however, was to move to be nearer her sister.

In November 2016 Child V was briefly in the care of her father. The parents were not living together and (at the request of the mother) the father had come to the home of the mother and the baby to care for the child whilst she went shopping. Child V's father noticed that Child V appeared lifeless and he called a friend for advice. Together they took Child V to a local health centre, where emergency life support commenced and the London Ambulance Service were called. Child V underwent CT scans that diagnosed a non-accidental head injury and rib fractures. Following brain stem tests medical care was withdrawn and Child V sadly died.

Learning points

A number of key learning points have emerged from this case review:

  • The importance of systems that do not rely on the presence of individuals.
  • Professionals must be alert to disguised compliance and demonstrate curiosity around children's wider social and family circumstances, particularly the role of fathers.
  • Appreciation of the impact that parental mental ill health and social isolation can have on children.

A number of actions have already been put into place as a result of this review, including strengthening the pre-birth referral pathway and protocols in relation to follow up for pregnant women who present at hospitals they are not booked at.

Response from the GSCB Independent Chair

Nicky Pace, Independent Chair of the Greenwich Safeguarding Children Board, said: "Our thoughts are with the family following the sad death of this young baby. The recent court proceedings found the child’s father not guilty of causing this tragic death, and the source of the fatal injury remains unknown.

"The Serious Case Review (SCR) found that this was an unforeseeable incident and that the injury to the child could not have been predicted. However, there were a number of learning points which arose during the review process, and the SCR did identify that more could be done to ensure that all parents of babies born in Greenwich are aware of the potentially catastrophic impact of shaking a young child.

"All agencies involved in the care of Child V have already put a number of actions in place. This includes a new system for processing pre-birth safeguarding referrals and a more proactive response to pregnant women who access ante-natal services at hospitals they are not booked at."

Download the Child V Serious Case Review report

Download the Child V factsheet

Serious Case Review - Children W

Statement by the GSCB Independent Chair

Nicky Pace, Independent Chair of the Greenwich Safeguarding Children Board, said: "Our review looked at all the circumstances of this case, and in particular the involvement of housing, health and other public sector agencies with the family. While the Board concluded that it is unlikely that these deaths could be considered either preventable or predictable, there are always lessons to be learned.

"This is a tragic case and our thoughts and sympathies are with all those affected by the very sad death of this mother and her two young children."

From the findings of this independent review, there are lessons to be learned regarding the understanding of the impact of a mother's mental health on the children and how professionals should 'Think Family' first, in order to better understand and consider the possible wider impact and risk within the family unit.

Further learning involves understanding the impact on a family of the housing situation, particularly homelessness and the level of stress under which people may be living. The report also considered how agencies reach out to people who have expressed suicidal thoughts.

The Board has shared its findings with all the relevant agencies and can reassure the public and others that the learning points outlined in the Report have not been delayed and that all the agencies have implemented changes as recommended in the report.

Nicky Pace, Independent Chair of GSCB, 17 January 2018

GSCB Serious Case Review - Child S

GSCB Serious Case Review - Child T

GSCB SCR Child T - Statement by the GSCB Independent Chair

"This is a tragic and distressing case and our thoughts and sympathies are with all those affected by Child T's death.

"As both the review and the Inquest concluded, it was clear that Child T felt she was no longer able to carry on living While the review found that with hindsight there were missed opportunities for services to coordinate better, there is no way to conclude with certainty that the outcome would have been different.

"For Child T's family members and friends – as well as for her teachers and others who had regular contact her - this has been, and remains, a distressing case. Our review reached the firm view that Child T found her secondary school to be a safe and nurturing environment in which she had been flourishing.

"Our review looked at the final three years of Child T's life and made a number of recommendations in relation to how professionals working with young people can better understand some of the issues that can lead to self-harm and suicide.

"At the inquest into her death the Coroner concluded that Child T had committed suicide. She found that there had not been any failings by the agencies involved with Child T leading up to her death that had caused or contributed in any way to the suicide. The coroner also found that Child T had been appropriately responded to and well supported by professionals working with her.

"She further acknowledged that through the Serious Care Review and other individual agencies' reviews there had been intensive investigation into the situation and therefore did not find it necessary to duplicate this work by making additional recommendations.

"I hope that those affected by her loss are able to take some comfort from both the findings of the Serious Case Review and from the outcome of the Inquest."

Nicky Pace, Independent Chair of GSCB, 18 February 2016

Learning from Serious Case Reviews: We regularly hold seminars for front line professionals and volunteers working with children and families in Greenwich to present the recommendations from local and national case reviews, and consider how they can be used to improve outcomes for children locally.

Please visit our Learning and Development section for more information on these training opportunities.