Case Reviews

Professionals and organisations protecting children need to reflect on the quality of their services. When things go wrong there needs to be a thorough analysis of what happened and why.

It’s important that lessons can be learnt and services improved to reduce the risk of future harm to children. When a child has been seriously harmed or died, and abuse or neglect is suspected or known to have happened, and there are concerns about the way agencies worked together, then the Wirral Safeguarding Children Partnership (WSCP) will undertake a Serious Case Review (SCR) (as defined in Working Together to Safeguard Children 2015). From September 2019 these will be called Child Safeguarding Practice Reviews (CSPR’s) in line with Working Together 2018.

Findings and recommendations from SCR’s and CSPR’s will usually be published in full in a report, which will be publicly available on this website. The purpose of SCRs and CSPR’s is to learn from what happened in individual cases so that future tragedies can be prevented.

Further information about how the WSCP undertakes statutory reviews and local learning reviews can be found here: https://www.wirralsafeguarding.co.uk/professionals/learning-and-improvement/

Chronologies

When deciding whether to initiate a statutory review, the WSCP will always gather together chronologies of involvement by individual agencies. The WSCP publishes guidance documents to help with completing chronologies:

Chronology Guidance for Agencies

Rapid Review Chronology Guidance for Agencies

Learning from National and Local SCR’s/ CSPR’s and Learning Reviews

The Child Safeguarding Practice Review Panel are an independent panel who oversee the statutory case review process. The panel publish both an Annual Review of all case reviews completed but also commissions reviews of national significance. The first of these reviews, about safeguarding children at risk from criminal exploitation – It was Hard to Escape, was published in March 2020 followed by a review of sudden unexpected cases in infancy where children were at risk of significant harm. The reports are available below.

Safeguarding Review Panel Annual Report 2018-19

It was hard to escape 7 Minute Briefing:

SUDI Review 7 Minute Briefing:

The next National Review is about Non-accidental injury in children under 1. The review and 7 minute briefing will be published here in the autumn.

Learning from Case Reviews

The NSPCC has published a briefing based on case reviews published since 2019 where children experienced domestic abuse. The briefing summarises and highlights the learning contained in the published reports, and can be accessed by clicking the image below:

Learning from local case reviews (2016-21)

The briefing below details the findings, themes and recommendations from 14 reviews undertaken by the WSCP between 2016 and 2021.

 

Wirral Serious Case and Child Safeguarding Practice Reviews

Child ‘Scarlet’ Child Safeguarding Practice Review 

This review was published on the 30th July 2021. This case centres on the multi-agency response to a child who made allegations of sexual assault against foster carers. The review highlights the complexities of cases which are considered by the Courts, the lengthy timescales involved, and how agencies supports a child if Courts do not proceed with a prosecution.

Seven recommendations were made, and all will now be actioned by the WSCP and its partners.

As well as the full report, also published is an Executive Summary, a 7 Minute Briefing and a learning poster.

Video Briefing

A narrated 30 minute briefing about the Scarlet CSPR is also available to watch on the WSCP Virtual Learning Event page (registration required).


Child ‘Liam’ Serious Case Review

The full report of the Child ‘Liam’ SCR was published on the 17th February 2020. Liam was 20 months old when he ingested a potentially lethal amount of methadone. Fortunately, Liam made a full recovery but the review highlights the issue of how children, particularly very young children, in substance misusing families are kept safe.

7 Minute Briefing:

Full SCR Report:

Executive Summary Report:

Summary Powerpoint Presentation:

Learning Posters:


Children I and J SCR

The full report of the Children I and J Serious Case Review was published on the 18th May 2018. The report can be found below:

Wirral SCR Child I and Child J

Summary of Learning Document:

Children I and J SCR Learning Summary


Child H SCR

The WSCB did not publish the full SCR report (July 2017) but did publish the recommendations in the document below.

The final action plan is available below.

Child H Serious Case Review – Recommendations, Outcomes and Learning Final Update November 18

Learning from the Serious Case Review

The Child H Serious Case Review has been completed. This means all actions from the 24 recommendations in the SCR report have been addressed. This can give us confidence that:

  • professionals are more aware of the signs of CSE, and know how to refer their concerns
  • organisations are ensuring staff at all levels are trained to recognise –no concern too minor- and respond to CSE
  • the partnership response to CSE concerns will be swift and effective
  • vulnerable children will be identified at the earliest opportunity

However, it is important to note completion of this action plan will not mean child sexual exploitation has disappeared or has been ‘solved’ in Wirral, as in any other borough in the UK. Professionals will be more aware but ‘The More You Know, the More You See’ applies and the safeguarding board expects cases will continue to be identified and must be responded to as quickly as possible.

Child Sexual Exploitation and exploitation of children in other ways, such as by criminal groups, are serious issues affecting local communities throughout the UK. The safeguarding board and partners will keep CSE, exploitation and abuse of children in our sights and continue to review and challenge each other to ensure a consistent and effective response.

The experiences suffered by Child H remind us all to remain vigilant and be aware of the signs of exploitation.


Child Sexual Exploitation Learning from national Serious Case Reviews and local Reviews:

WSCB National Learning from SCR’s – CSE

SCR Learning Poster Teen Awareness female

Mini Teen awareness f

SCR Learning Poster Teen Awareness male

Mini Teen awarness m


Learning from Multi-agency Learning Reviews

The WSCP also undertakes reviews of cases which do not reach the threshold for a SCR but are reviewed because the case is likely to provide useful multi-agency learning or the circumstances of the case were unusual. Summaries of these cases are published and the  the learning is shared with the partnership and included in WSCP training.

In April 2020 the WSCP made the decision going forwards to refer to all cases (CSPR’s and Learning Reviews) by a name (not the real name) of the child/ren.

 

Anderson Children – this case centred on five siblings who were removed from the care of their parents due to neglect. The case highlights the impact of long term neglect and where opportunities can be missed to intervene as early as possible.

Matthew – was an 18 year old care leaver who tragically took his own life shortly after his 18th birthday.

 

Learning from Reviews – Key Messages

The WSCP also periodically distils lessons from Serious Case Reviews into posters for professionals. These can be downloaded here. There is space on the posters for you to add the contact details of your safeguarding lead:

SCR Learning Poster Young Children

Mini Young Children and Babies
SCR Learning Poster Unborn Awareness

Mini Unborn Awareness

SCR Learning Poster Questionning Poster

Mini Questionning
SCR Learning Poster Online Abuse

Mini Online Abuse
SCR Learning Poster Neglect Vulnerable Children

Mini Neglect
SCR Learning Poster Neglect Risk Factors

Neglect Risk Factors
SCR Learning Poster Information Sharing

Mini Info Sharing
SCR Learning Poster Education

Mini Education
SCR Learning Poster CSE

Mini CSE
SCR Learning Poster Daniel Pelka

Mini Pelka

Referring Cases to the Wirral Safeguarding Children Partnership

All agencies and professionals in the WSCP partnership can refer cases to be considered for a multi-agency learning review. Before a referral is made the professional should discuss the case with their safeguarding lead. Professionals can also consult about potential referrals with the WSCP Business Manager ([email protected]).

Referrals are made using the Case Referral Form (available below). Completed Forms should be emailed to:

[email protected]

WSCP-Case-Review-Referral-Form 2020

 

Safeguarding Practice Review Panel

On the 29th June 2018 the National Panel for Serious Case Reviews was replaced by the new National Child Safeguarding Review Panel.

The Child Safeguarding Practice Review Panel is responsible for commissioning and supervising reviewers for national child safeguarding practice reviews – these will replace Serious Case Reviews as new safeguarding arrangements take effect.

The purpose of a national child safeguarding practice review is to identify any improvements that should be made by safeguarding partners or others to safeguard and promote the welfare of children.

Duty on Local Authorities to refer Serious Incidents

Local Authorities are required to notify the Child Safeguarding Practice Review Panel of incidents where they know or suspect that a child has been abused or neglected and:

  1. the child dies or is seriously harmed in the local authority’s area; or
  2. while normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

These notifications should be made within five working days of the local authority becoming aware of the incident.

Local authorities should use the DfE’s online notification system to notify the Panel.

LA’s are also required to report the incident, within the same five working days, to the relevant Safeguarding Partnership.

The procedure for notifications is detailed here:

 

Notifiable Incidents

For guidance about how to inform the WSCP of a notifiable incident involving a child please follow the link:

www.wirralsafeguarding.co.uk/notifiable-incidents-involving-children