Serious Case Reviews

‘Learning the Lessons’ from Child Deaths and Serious Case Reviews

The Birmingham Safeguarding Children Partnership's Local Learning and Improvement Framework enables organisations to be clear about their responsibilities, to learn from experience and improve services as a result.  The findings from Serious Case Reviews (SCRs) are an essential element of this process and provide organisations with an opportunity to reflect on the quality of their services and learn from their own practice and others.  

  • The learning and good practice that emerges from SCRs is shared at a national, regional and local level to maximise the opportunity to embed key learning, particularly those organisations who work with and support children and families in Birmingham.
  • The BSCP rigorously monitors implementation of the findings and seeks assurance and evidence from organisations on how learning is taken forward from these tragic cases.   
  • There is a direct correlation between size, deprivation and diversity of a child population and the number of SCRs commissioned by Local Safeguarding Children Boards.
  • The number of SCRs undertaken in Birmingham is comparable with other major cities and conurbations across the country.  Over a ten year period an average 2.7 SCRs have been commissioned each year, which  equates to 1.6 % of the total SCRs undertaken in England, when the City has 2% of the country’s child population. Therefore there has not been a greater number per capita of child deaths through abuse or neglect in Birmingham, or SCRs than in England as a whole. 
  • LSCBs have responsibility for the review of all child deaths (under 18 years), through the Child Death Overview Panel arrangements (click here for further information regarding CDOP). The analysis of environmental, social, health and culture factors enable the aggregated findings to inform both national and local strategic planning to enhance services to reduce the number of child deaths in the future. 
  • The format and content of the SCR report has changed overtime to take account of the revision of national guidance set out in ‘Working Together to Safeguard Children’ and direction from Ofsted.  
  • The criteria for a SCR focuses on when a child dies or is seriously harmed and abuse or neglect is known or suspected. Of those cases that have been commissioned in Birmingham, three cases fell into the category of serious harm. SCRs are independent open investigations aimed at identifying the important learning for professionals across a broad spectrum of organisations.

Chart 1 below provides an overview of the number of SCRs commissioned during the last ten years. Chart 2 below indicates the number of child deaths each year and the small proportion of deaths that are attributable to child abuse and result in the commissioning of a SCR.

The BSCP Annual Report 2017/18 provides detailed analysis of why children die and the action that is being taken to reduce the number of child deaths.    

Chart 1

Published SCRs

Chart 2

Number of CD in comparision to SCR

Please see the below link for the most recent SCR’s

The most recent published Serious Case Reviews will be available read and download.  However, in accordance with National Guidance published in July 2018, after three years the published SCR reports are archived, but available on request via BThis email address is being protected from spambots. You need JavaScript enabled to view it.   

BDHR 2013 14/02

BSCB 2016-17/1 
Briefing Note

BSCB 2015-16/04
Briefing Note

BSCB 2015-16/01
Briefing Note

The National Case Review Repository hosted by the NSPCC retains an on-line library of all published Serious Case Reviews in England, which can be  accessed by the public via  the below link: 

Page Reviewed: 20.02.2019

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